Medical Transcription Gastrointestinal Consultation Example Report
DATE OF CONSULTATION: MM/DD/YYYY
REQUESTING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Abdominal pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Hispanic female who acutely developed lower abdominal sharp pain approximately three days ago. The pain persisted for several hours before generalizing to a dull ache throughout her abdomen. It was associated with a migraine headache with nausea and vomiting.
Since then, she has had the pain persist for several hours. On Friday, she had diffuse abdominal achiness, which again lasted hours and then recurred again yesterday. Yesterday, she was having some sharp pain again, which was 9/10, so she came to the emergency room. Today, the pain is only present to palpation.
The patient reports a similar episode of pain approximately a month ago, but it was a dull ache, which did not last nearly as long. Otherwise, she has never had pain like this before. The dull ache is eased by lying in a fetal position. Nothing relieves the sharp pain. In particular, she does not note any change in the pain with passage of flatus or with any oral intake. Her last bowel movement was prior to the onset of pain three days ago; it was slightly softer than usual.
HOME MEDICATIONS: Multivitamin and topical acne treatment.
ALLERGIES: No known drug allergies.
PAST MEDICAL HISTORY: Four urinary tract infections over the last four years.
PAST SURGICAL HISTORY: None.
SOCIAL HISTORY: The patient denies alcohol, tobacco or drug use.
FAMILY HISTORY: Negative for GI disease, except for diverticulosis or diverticulitis in her grandmother.
REVIEW OF SYSTEMS: Negative for fevers, chills or sweats. She denies anorexia or unexpected weight change. She denies heartburn, regurgitation, dysphagia, odynophagia or early satiety. She continues to have low-grade nausea. There has been no hematemesis, melena, hematochezia or mucoid stools. The patient denies diarrhea or constipation. There is no chest pain or shortness of breath. No skin lesions other than the acne. She develops low back pain early in her menses. It worsens with physical activity. There is no other back pain or stiffness. There is no other joint pain or stiffness.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: Reveals a well-developed and well-nourished Hispanic woman in no acute distress.
VITAL SIGNS: Temperature 97.8, pulse 68, respirations 18, blood pressure 112/78, weight 132 pounds.
HEENT: Normocephalic and atraumatic. Conjunctivae pink. Sclerae anicteric. Mucous membranes moist without lesions.
NECK: Supple.
CHEST: Clear to auscultation and percussion.
HEART: S1, S2, without S3, S4 or murmur.
ABDOMEN: Normoactive bowel sounds, soft, nondistended with left lower quadrant fullness. There is mild right lower quadrant tenderness to deep palpation. No masses are detected in this area.
BACK: Without spinal, lumbosacral or CVA tenderness.
EXTREMITIES: Without clubbing, cyanosis or edema.
SKIN: Without spider angiomata, superficial collateral vessels or palmar erythema. There is some mild facial acne.
NEUROLOGIC: She is alert and oriented x3. Cranial nerves II through XII are grossly intact. She moves all extremities without difficulty.
LABORATORY DATA: Yesterday was sodium 140, potassium 4.2, chloride 108, CO2 of 26, glucose 86, BUN 12, creatinine 0.7, calcium 9.6, total protein 8.2, albumin 4.2, total bilirubin 0.6, AST 22, ALT 32, alkaline phosphatase 88, amylase 82, lipase 218, white count 6.6, hemoglobin 14.6, hematocrit 42.6, MCV 90.2, RDW 12.6, platelets 246,000, polys 73%, lymphs 19%, monos 7%, and eos 1%. Urinalysis unremarkable. Lab data today reveals white count 5.2, hemoglobin 11.2, hematocrit 33.6, platelets 202,000, polys 58%, lymphs 30%, mono 11%, and eos 1%.
CT scan of the abdomen and pelvis was performed with and without contrast. Left lobe of the liver appeared prominent extending over the anterior lateral surface of the spleen superiorly. A 5 mm lesion was seen laterally and superiorly within the left lobe, which was not seen on delayed imaging. Right kidney demonstrated a well-circumscribed 1 cm lesion. The examination was remarkable for rim-enhancing lesions within in the right adnexa, measuring up to 2 cm with infiltration of the surrounding fat and an oblong lobulated complex mass in the left adnexa.
ASSESSMENT:
1. Left and right adnexal lesions.
2. Abdominal pain.
RECOMMENDATION: There is no apparent GI etiology for her symptoms. Suspect they are related to her adnexal lesions. Further workup as per Dr. Jane Doe. The patient should follow up for persistent nausea or if she has pain after the mass has been evaluated and treated. All questions were answered and the case was discussed with Dr. Jane Doe.
