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Thank you for referring John, a teacher, for review of chronic abdominal pain. Issues: 1. Chronic abdominal pain 2. Dyspepsia Medication List: Omeprazole 20mg daily, paracetamol as needed. Recommendations: 1. Consider upper endoscopy. 2. Advise on dietary modifications. Consultation Summary: John presented with a several-month history of intermittent, crampy abdominal pain, primarily in the epigastric region. He also reports frequent episodes of dyspepsia, including heartburn and acid reflux. The pain is often triggered by meals, particularly those high in fat. He denies any changes in bowel habits, weight loss, or GI bleeding. He has tried over-the-counter antacids with limited relief. Past medical history is unremarkable. He does not smoke, drinks alcohol occasionally, and has no known allergies. Examination Findings and Results: - Vitals: BP 130/80, HR 78, RR 16, Temp 37.0°C - Physical examination findings, especially abdominal exam: Mild tenderness to palpation in the epigastric region, no guarding or rebound tenderness. Bowel sounds were normoactive. - Investigation results including imaging (CT, MRI, US), endoscopic findings, lab tests (LFTs, CBC, inflammatory markers): Blood tests were within normal limits. Intestinal Ultrasound: State that intestinal ultrasound was performed with patient consent Include probe details: XX linear and YY curved Detailed findings by segment including bowel wall thickness (mm), Doppler signal presence and pattern, bowel wall stratification, mesenteric hyperechogenicity, peristalsis, upstream diameter. Colonic findings including segmental bowel diameter, contents, haustra coli presence, acoustic shadowing. IUS Metrics: - Most affected segment: Proximal jejunum - Max bowel wall thickness in mm: 3.2mm - Colour Doppler signal grade (0–3): 1 - Mesenteric i-fat: absent - Bowel wall stratification: present - Max right colon diameter: 4.1cm - Haustra coli: present - Posterior acoustic shadowing: present Summary of IUS findings: Mildly increased bowel wall thickness in the proximal jejunum, with normal peristalsis and no evidence of significant inflammation. Assessment & Plan: 1. Gastrointestinal Issue or Condition - Assessment including likely diagnosis and rationale: Likely functional dyspepsia, given the symptoms and normal blood tests. Rule out other causes with further investigations. - Differential diagnosis: Peptic ulcer disease, gastritis, irritable bowel syndrome. - Planned investigations: Upper endoscopy. - Medical treatment plan: Continue omeprazole 20mg daily. Consider adding a prokinetic agent if symptoms persist. Discuss the potential side effects of the medication. - Lifestyle advice: Advise John to avoid trigger foods, eat smaller meals, and avoid eating late at night. Encourage regular exercise. - Planned follow-up timeline and purpose: Follow-up in 4 weeks to review symptoms and endoscopy results. - Referrals made or planned: None. 2. Additional GI Issue or Condition - Repeat above structure as needed for additional conditions Additional Notes: - Patient education provided: Discussed the nature of functional dyspepsia and the importance of lifestyle modifications. - Symptom monitoring advice and warning signs to seek urgent care: Advised John to seek immediate medical attention if he develops severe abdominal pain, bloody stools, or significant weight loss. - Any patient or family concerns discussed: John expressed concerns about the potential for a serious underlying condition, which was addressed. Endoscopy Plan: Pre-Procedure Instructions: Dietary, medication and prep instructions: Patient to fast for 8 hours prior to the procedure. Stop omeprazole 1 week before the procedure. Procedure Details: Type of endoscopy, date/time, location: Upper endoscopy, 15 November 2024, 10:00 AM, Endoscopy Suite. Consent: Details of informed consent process including risks discussed: Risks and benefits of the procedure were discussed with John, and informed consent was obtained. Post-Procedure Care: Diet/activity instructions, follow-up timeline: Clear liquids after the procedure, followed by a light diet. Follow-up with me in 2 weeks. "Thanks again for involving me in the care of John, I will review them in 4 weeks." "AI medical software was used during this consultation with patient permission."