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GI Consultation Medical Transcription Transcribed Sample Report / Example




REASON FOR CONSULTATION:  Opinion and evaluation regarding a nonspecific GI bleed as manifested by bleeding per rectum/bloody stools.

HISTORY OF PRESENT ILLNESS:  The patient is a (XX)-year-old man with a history of coronary artery disease, status post CABG, who presented to the hospital last night after multiple episodes of bloody melenic stools. The patient apparently was in his usual state of health up until about last night, when he thought he was having an episode of diarrhea. What came out were some dark loose stools along with dark-colored blood. The patient had multiple episodes of these bowel movements that consisted of blood mixed with stools. The patient has not experienced any pain or discomfort during this time. No fevers or chills. No abdominal cramping. No sick contacts at home. The patient has not had any history of peptic ulcer disease in the past though the patient did apparently have a history of Meckel's diverticulum status post surgery. The patient is on an aspirin presumably due to his coronary artery disease and takes an adult aspirin daily. No passage of blood that was bright red in character. The patient did have an NG lavage that was apparently pink tinged. The patient himself was uncertain whether or not this may have been blood versus some fruit juice which he recently had prior to his arrival to the emergency room. The patient's hemoglobin initially was 10.6, currently it is 9.5. There does not appear to be any modifying factors in regards to this bleeding episode though he currently is maintained on a proton pump inhibitor drip.

PAST MEDICAL HISTORY:  Includes a 4-vessel CABG in the past secondary to coronary artery disease. He has a history of hyperlipidemia as well as history of the aforementioned Meckel's diverticulum status post resection.


CURRENT MEDICATIONS:  Include only his PPI drip as well as some maintenance IV fluids. As an outpatient, he was taking Vytorin as well as an adult aspirin a day.

SOCIAL HISTORY:  The patient quit smoking about 10 years ago. No alcohol or drugs.

FAMILY HISTORY: Appears noncontributory.

REVIEW OF SYSTEMS:  GENERAL:  The patient denies any significant weight or appetite changes. No unusual fevers reported. EYES, EARS, NOSE, THROAT:  No recent changes to vision or hearing. No swallowing difficulties reported. RESPIRATORY:  Denies shortness of breath, wheezing or coughing up of blood. CARDIOVASCULAR:  Denies any current chest pains, palpations or shortness of breath while lying down. GASTROINTESTINAL:  GI review of systems is as noted in the history of present illness. GENITOURINARY:  He denies any gross dysuria or hematuria. SKIN:  Denies jaundice or unusual rashes or sores. NEUROLOGIC:  Denies seizures, strokes or loss of consciousness. HEMATOLOGIC:  Denies easy bleeding or excessive bruising. No history of frequent infections. PSYCHIATRIC:  Denies depression, panic attacks or anxiety disorder.

VITAL SIGNS:  Temperature 98.6, pulse 66, respiratory rate 16, blood pressure 114/62, O2 saturation 98% on room air.
GENERAL:  No acute distress. The patient was lying in bed cooperative with examination.
HEENT:  Normocephalic and atraumatic. No scleral icterus or pallor appreciated. Conjunctivae are pink. Oropharynx slightly dry, otherwise clear.
NECK:  Supple. No gross thyromegaly appreciated. No obvious lymphadenopathy palpated.
LUNGS:  Clear to auscultation bilaterally. No wheezing was appreciated.
HEART:  Regular rate and rhythm. Positive S1, S2. No significant murmur was appreciated.
ABDOMEN:  Mildly obese, soft, nontender, nondistended with normoactive bowel sounds. No rebound or guarding was appreciated. A well-healed scar was appreciated from the patient's history of previous surgery.
EXTREMITIES:  No clubbing, cyanosis or edema.
SKIN:  No jaundice appreciated. No obvious rashes or sores.
NEUROLOGIC:  Cranial nerves appeared grossly intact. Gross motor movement was appreciated to bilateral upper and lower extremities.
PSYCHIATRIC:  The patient was alert and oriented x3. Appropriate affect and mood.

LABORATORY DATA:  Glucose 132, BUN 28, creatinine 1.3, potassium 3.6, sodium 143, chloride 111, CO2 of 24, calcium 8.4, AST 22, ALT 21, alkaline phosphatase 47, total bilirubin 0.4. WBC count 6.6, hemoglobin 9.4, platelet count 178, INR 1.2.

IMPRESSION: The patient is a (XX)-year-old man with a history of coronary artery disease and hyperlipidemia, on aspirin, with a nonspecific GI bleed. By history, the patient appears to have passed dark maroon stools that may be compatible potentially with brisk GI bleeding from above. The patient's NG tube lavage revealed pink-tinged fluid. Potentially, this may represent bleeding from a region beyond the pylorus, namely the duodenum. The patient did have an elevated BUN to creatinine ratio, which may also support a possible upper GI bleed. Considering the patient's age, however, some consideration may be given for possible lower GI pathology though I believe, at least by history, an upper GI source may be a bit more likely.

RECOMMENDATIONS:  Considering the above, I have recommended that we start the evaluation with an esophagogastroduodenoscopy. Indications, risks and alternatives for the esophagogastroduodenoscopy were discussed with the patient. Discussion of risks included risks of bleeding, perforation, possible surgery as well as potential anesthesia complications. The patient demonstrated good understanding of the above and has chosen to proceed. Should the esophagogastroduodenoscopy be unremarkable in explaining the patient's symptoms, we will plan for a colonoscopy tomorrow with a colon preparation tonight. Indications, risks and alternatives for the colonoscopy were also explained to the patient. Discussion of risks included risks of bleeding, perforation, possible surgery, anesthesia complications as well as potential missed lesions. The patient demonstrated good understanding of both examinations and has chosen to proceed as needed. In the meantime, I would recommend that the patient continue his proton pump inhibitor drip, maintain NPO, and continue to follow the patient's serial hemoglobin. Additional recommendations to follow after the above has been completed. Do feel free to contact me with any additional questions or concerns.

Thank you very much, Dr. Doe, for this referral. I will be happy to participate in this pleasant patient’s care.

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