GASTRO TEST FILES

GASTRO_T1

Gastroenterology

LETTER

Date

Name

Address

City, State, Zip

Re:

Dear Bob:

This is a follow-up letter to our brief discussion.  As a background, she has had 20 years of “nervous stomach,” describing abdominal discomfort with certain foods and stress.  She would get relief intermittently with Donnatal, Di-Gel, and Maalox.  Additionally, she has been taking 8 Excerdrin per day for approximately 20 years.

More recently for her shoulder problem, she was treated with prednisone, Naprosyn, Flexeril, and Excedrin with codeine, Tylenol No: 3 Percodan, having been off all prednisone and Naprosyn for approximately 4 weeks.  However, despite being off those medications, she still describes some “indigestion,” described as a midepigastric discomfort associated with mild nausea.  This discomfort is worse with food and with tight clothes.  She describes loss of appetite and basically being afraid to eat anything.  She has no visible bloating, vomiting, acid regurgitation, nocturnal symptoms, or dysphagia.  She does describe some improvement in the symptoms with soda crackers, creme de menthe, and liquid Maalox, as well as belching.  She continues to take 8 Excedrin per day.

Her physical examination was remarkable for findings of a right pleural effusion, and her stool was Hemoccult positive.

In view of her many years of dyspeptic symptoms, her recent multiple drug ingestion, as well as the continued aspirin intake, one has to presume that her midepigastric discomfort and nausea are due to these multiple medications and the continued use of aspirin.  In view of this likelihood, it would seem most reasonable to treat her presumptively with Tagamet as well as taking her off regular aspirin and placing her on Ectorin (the enteric-coated aspirin), which seems to have less gastroduodenal effects.  To this end we started her on Ecotrin, Tagamet, and should she have no improvement in her symptoms over the next several weeks, then endoscopy is recommended to evaluate the source of her pain.

Thank you, Bob, for asking me to see me this patient, and should she have no improvement, I will keep you informed of the results of her endoscopy.

Sincerely,

Name.

GASTRO_T2

Gastroentrology

CONSULTATION

PRESENT ILLNESS:  She is admitted to the hospital because of vomiting and epigastric discomfort for 1 or 2 days prior to admission.  At the time of admission, x-rays of the abdomen showed small bowel air-fluid levels and 1 dilated loop of small bowel.  A Gastrografin study was subsequently done, which showed no obstruction, transit through the small bowel in 45 minutes, with contrast material reaching the colon 45-minutes.  No dilated loops were observed at the time of Gastrografin studies were done.  Today she is much better, has no pain or obstruction or distention in the abdomen.  She has had previous abdominal surgeries including cholecystectomy and uterine suspension.  Other details of the history will be documented by the attending physician.

EXAMINATION:  A brief examination is done, shows that she has a pacemaker, and the heart is regular at about 70 per minute.  She does have a high-pitched systolic murmur at the apex of the heart suggestive of mitral insufficiency.  Breath sounds are good, lungs are clear.  The abdomen is slightly rounded.  The abdomen is soft, no enlarged organs or masses are palpated, and there is no tenderness.  Careful listening to the abdomen fails to disclose any bruit.  A brief neurological examination shows that the pupils are equal and react light, and extraocular muscles are normal. 

Grip strength is normal and equal.  Finger-to-nose test and heel-to-shin test are normal.

Knee jerks are normal.

The question at this point is to try to determine a cause for her presenting symptoms.  I should note that she has had similar symptoms on several occasions in the past, and also has a history of having had a stroke before as well as other medical conditions for which she is being treated.

DIFFERENTIAL DIAGNOSES:  Differential of diagnoses must include

1.  Ileus due to compression fracture of spine.  She had a compression fracture involving T8 and T12.  At the present time she is not complaining of any back pain.  However, compression fracture is a good cause of ileus.

2.  Ileus due to obstructive colon lesion.  This is possible.  It would have to be an intermittent obstruction in her case.  If there were a type of partial obstruction of the colon so that there was intermittent backup into the small intestine, there is a possibility that such a picture could occur.  A barium enema would be helpful.

3.  Ileus due to ischemia.  She is in the right age group for mesenteric ischemia.  I did question her closely as to the possibility of pain after meals and particularly pain after large meals.  She denies having any pain.  If this is a consideration, mesenteric angiography would be helpful, but abdominal angina is not a common condition.

4.  Ileus due to a stroke, TIA (transient ischemic attack), or other CNS (central nervous system) event.

I could not find a neurological deficit on my examination today.  However, the fact that she has had a stroke in the past makes this a possibility.  A CT (computed tomography) head scan might be helpful.

5.  Pseudo-obstruction due to diabetes, thyroid, or parathyroid lesion.  She quite obviously does not have familial Pseudo-obstruction, as she has not had these symptoms from the childhood.  However, she does have maturity-onset diabetes.  The transit time through the small bowel was not slowed, which lessons the likelihood that this is the explanation for these symptoms.  However, it is worth a consideration, and I believe that getting a thyroid panel would be helpful and to recheck the serum ionized calcium.  Her present calcium level at 8.9 is normal, but her albumin is quite low at 2.4, which means that her ionized calcium might be high.

6.  Pseudo-obstruction due to drugs.  She is taking very few medications.  Lomotil is on order for her, but she and the nursing home personnel deny that she had any diarrhea or had any need for Lomtil during the days prior to this event.

7.  Pseudo-obstruction due to collagen disease, amyloidosis, or other such chronic disease.  Other signs of these diseases are not present.  These are unlikely.

COMMENT:  I am suggesting that this patient have a barium enema as soon as it is feasible for her to do so.  I am also getting an order for a thyroid panel and serum ionized calcium.  Other tests as suggested above will depend more upon how the clinical picture develops in the future.