GASTRO FILES

GASTRO_3

CHART NOTE

A 23-year-old gentleman in good health until 4 to 5 days ago, when he developed acute onset high fever, abdominal cramping, nausea, and profuse watery diarrhea.  Temperature was up to 102 at home.  The patient has continued to work despite feeling ill but today became faint.

On examination, he is a pleasant young man who is in no acute distress.  Blood pressure is 98/64.  HEENT clear.  Chest clear.  Cardiac examination reveals regular rate and rhythm at about 100.  Abdomen soft, diffusely tender to palpation.

ASSESSMENT:  Acute viral gastroenteritis with probable dehydration.

Given the severity of his symptoms, I am going to go ahead and treat expectantly with antibiotics, obtain a stool culture as well as Gram stain, begin on Bactrim DS, Phenergan for nausea, Donnatal for abdominal cramping.  Patient should definitely rest at home for next several days.  To follow first clear liquid, then BRAT diet.  Return to clinic p.r.n.

GASTRO_6

LETTER

Date

Name

Address

City, State, Zip

Re:

Dear Doctor

I have seen the above-named patient for several visits since her colonoscopy, and I wanted to update you about what has transpired.  After the colonoscopy, I increased the Azulfidine to 2 q.i.d.  I also sent stool for C. difficile, which was negative, and ordered an upper GI with a small bowel series.  This showed a small sliding-type hiatal hernia with rapid transit time through the small bowel.  The remainder of the examination was normal.

I saw this patient again 3 months later, at which time she had a fever and sweats with temperature of 103 degrees.  I referred her to your office to further assess whether the Azulfidine or Crohn’s is the source of her fever.  Also, when she took Lomotil for loose stools, she became obstipated.  Metamucil may help avoid rebound constipation.

Thank you for allowing me to participate in this very lovely patient’s care and management.

Very truly yours

Name.

GASTRO_7

LETTER

Date

Name

Date

City, State, Zip

Re:

Dear Dr. (blank)

I was embarrassed to find out that through a clerical slipup, this consultation note was not dictated promptly, as it should have been.  Please accept my apology.

I personally reviewed the air contrast barium enema.  The radiologist’s impression was that there was a soft tissue mass on the terminal ileum.  My impression was that this could possibly be a Meckel’s, although this would be very unusual.  This is probably lymphoid hyperplasia and is unimpressive.

My impression is irritable bowel syndrome and possibly a Meckel diverticulum.  Therapeutically, I suggested he go on a high-fiber diet, and our nursing staff talked to him extensively about the use of bran.  He was given 3 Hemoccult test cards and these were returned, and all 3 were negative.

Unless symptoms recur, I do not believe a further invasive workup is necessary at this time.

Thank you very much for referring me this patient, and again I apologize for the delay in sending you this note.

Sincerely

Name.

GASTRO_8

THE HISTORY AND PHYSICAL EXAMINATION

HISTORY:  A 40-year-old previously healthy female who complains of ongoing epigstric pain.  She was seen here and evaluated, then treated with Tagamet, Mylicon, and Donnatal without significant improvement in her symptoms.  There has been no vomiting or diarrhea although the patient is nauseated and has lost her appetite.  There has been no fevers, chills, or sweats.

PAST MEDICAL HISTORY:  Her past medical history includes cysts excised from both breasts, and a hysterectomy without oophorectomy because of infections and bleeding.

FAMILY HISTORY:  Her family history includes peptic ulcer disease in both parents and gallbladder trouble experienced by her mother.

PHYSICAL EXAMINATION:  The epigastrium is mildly tender and the gallbladder is not palpable or tender.

The bowel sounds are active in a soft, flat abdomen that is tender only in the epigastrium.  The back in the region to which the pain radiates is not tender.

LABORATORY FINDINGS:  The amylase, BUN, electrolytes, and glucose are all within normal limits.  The CBC shows a white count of 10,700 with 7% bands and 73% segs.  The hematocrit is 44.  An acute abdomen series tonight is unremarkable.

DIAGNOSIS:  Abdominal pain, probable peptic ulcer disease with posterior penetration.

DISPOSITION:  The patient is to be admitted and an I.V. will be started, Demerol and Tagamet will be given, and the upper GI and gallbladder evaluation carried out.

GASTRO_9

HISTORY AND PHYSICAL EXAMINATION

HISTORY OF PRESENT ILLNESS:  Patient is a 31-year-old white male who complains of severe right lower quadrant pain.  He stated that he noted some onset of periumbilical pain several days ago and has had intermittent pain since then.  Over the past day he has noticed the pain migrated to the right lower quadrant and has become persistent.  He gas noticed some fever today.  Notes mild nausea but no vomiting.  Denies diarrhea.  His last meal was at six this evening.

PAST MEDICAL HISTORY:  He has no history of medical problems or surgery in the past.  He is on no medications.

PHYSICAL EXAMINATION:  He is a well-developed male in mild distress.  His temperature is 101.3, pulse 88, resouratiry rate 16, blood pressure 108/72.

SKIN:  The skin is warm and dry.

HEENT:  Sclerae anicteric.  Conjuctivae pink and moist.

LUNGS:  Lungs are clear.

HEART:  Heart tones are normal.

ABDOMEN:  Abdomen reveals normal tone, heme-negative stool.  No masses or tenderness.

EXTREMITIES:  Extremities reveal no clubbing, cyanosis, or edema.

NEUROLOGICAL:  He is alert and oriented.  Nonfocal exam.

LABORATORY DATA:  White count is 10.2 with 64 polys and 1 band.  Hemoglobin and hematocrit, PT, PTT, electrolytes, BUN, creatinine, and glucose all normal.  Abdominal series is unremarkable.

In the emergency department an I.V. line of D5/Ringer lactate at 125 cc was initiated.

The patient’s exam merits an exploratory laparotomy to rule out appendicitis.

DIAGNOSIS: Rule out appendicitis.

GASTRO_10

DISCHARGE SUMMARY

HISTORY OF PRESENT ILLNESS:  This 56-year-old gentleman was admitted after consuming aspirin and Feldene the night prior to admission, followed 6 hours later with awakening at 3 a.m., suffering a burning sensation in his stomach and cold sweats.  He later on the day of admission visited the acute care center where he was found to have guaiac-positive melenic stools, anemia at hemoglobin 11 and hematocrit 32%, with BUN 40.  He had no orthostatic changes at the time.  Gastroduodenoscopy, which after being performed, revealed an active duodenal ulcer with associated duodenitis (the cause of his bleeding) and several small antral erosions.  Incidental finding of a Schatzki ring in the esophagus was noted, as well as a hiatus hernia.

Admitted for observation and treatment with Zantac 300 mg q.12h. p.o.  His final hemoglobin was 10.1 and hematocrit 29.0.  At the time of discharge he was considering entering the research program currently in progress and, as per protocol restrictions of the research study, no H2 blockers were given.

DISCHARGE MEDICATIONS:  Medications at the time of discharge include:

1.  Maalox/Mylanta 30 cc p.o. p.c. and h.s.

2.  Zyloprim 300 mg p.o. q.d.

3.  Lorelco 2 tabs p.o. b.i.d.

With meals.

4.  Questran 1-1/2 scoops p.o. b.i.d.

5.  FeSO4 300 mg 1 p.o. b.i.d.

6.  Restoril 30 mg p.o. h.s. p.r.n.

FINAL DIAGNOSIS

1.  Upper gastrointestinal bleeding secondary to active duodenal ulcer with surrounding duodenitis, possibly secondary to aspirin and Feldene intake.

2.  Gastric erosions (antral).

3.  Schatzki ring.

4.  Hiatal hernia.

5.  Duodenitis.

6.  Status post coronary artery bypass grafting for atherosclerotic coronary artery disease.

7.  Gout.

PROCEDURES:  Esophagogastroduodenoscopy.

GASTRO_12

OPERATIVE REPORT

UPPER ENDOSCOPY NOTE

INDICATIONS:  This 47-year-old white female was referred for evaluation of intermittent bright red rectal bleeding.  The patient was evaluated 2 years ago when she had significant rectal bleeding with gross hematochezia.  At that time, colonoscopy was normal.  The bleeding was so severe that the required 2 units of packed RBCs in transfusion.  The patient has had another episode subsequently without seeking medical attention.  When she had another episode in the last month, she ought followup.

The patient also described lower abdominal discomfort, which is a burning sensation.  She has not noted any effect by food ingestion.  There is no previous history of peptic ulcer disease.  The patient feels that the bleeding often will be heralded by this abdominal discomfort.  In light of these findings, upper endoscopy as well as colonoscopy was recommended to the patient.  The risks of bleeding were discussed, and the patient agrees to proceed.

PREMEDICATION:  Demerol 60 mg I.V., Versed 3 mg I.V. with saline flush.

FINDINGS:  The Olympus XQ upper endoscope was inserted under direct vision.  The hypopharynx appears normal.  The esophagus shows normal mucosa throughout, with the Z-line pristine.  The stomach shows a small amount of bile-tinged fluid which is easily aspirated.  The mucosa in the stomach is completely normal including retroflexed view of the angularis, body, fundus, and EG junction.  The pylorus is patent and easily allows passage of the endoscope.  The duodenum shows normal mucosa of the bulb and C-loop to the distal second portion.  Patient tolerated the procedure well.

ASSESSMENT:  Normal upper GI endoscopy.