Gastroenterology Case Studies

-->

DISCHARGE SUMMARY

The patient, a 43-year-old white man, a chronic alcoholic with advanced cirrhosis and hiatus hernia, developed distal esophageal stenosis.  An acute attack of dysphagia and choking led to hematemesis.  The patient began to lose weight 10 months ago, and 5 months later his abdomen began to swell, and he quickly regained the 30 pounds he had lost.  He had no dysphagia nor recognized bleeding.  The day before he was first examined, he suddenly became unable to swallow while eating lunch.  He choked and coughed, vomited hard, and then brought up a cupful of fresh blood.

Examination upon hospitalization showed moderate chronic illness, but no apparent acute problem at the moment.  There had been no further bleeding.  The vital signs were normal.  There were classical signs of alcoholic cirrhosis, hepatomegaly, spider angiomata, and muscle wasting about the shoulders and zygomas.

LABORATORY FINDINGS

Tube aspiration of the stomach showed no blood.  Admission hemoglobin was 12 g and hematocrit 38.  The serum alkaline phosphatase was 17 King-Armstrong units and serum bilirubin 2 mg.

X-RAY STUDIES:  Upper gastrointestinal roentgen study was interpreted as showing a small direct hiatus hernia, distal esophagitis, and a low-grade esophageal stricture secondary to the esophagitis.  Esophageal varices could not be demonstrated.  Except for hiatus hernia, the stomach and duodenum were considered normal.

HOSPITAL TREATMENT

The day following hospitalization, esophagogastroscopy was carried out.  Direct hiatus hernia and esophagitis were confirmed.  Varices were not found.  There was no esophageal stricture; instead, the distal esophagus seemed soft and mobile, and permitted easy passage of the 10-mm esophagoscope.  A
6 x 5-mm irregular ulcer was found in the hyperemic mucosa just above the esophagogastric junction.  There was no Mallory-Weiss lesion.

PATHOLOGIST’S REPORT

Esophageal biopsy specimens contained adenocarcinoma.  Peritoneoscope examination showed metastases scattered over a finely nodular cirrhotic liver.

FINAL DIAGNOSES

1. Primary adenocarcinoma of the herniated gastric cardia with extension up the esophagus and hepatic metastases.

2. Alcoholic cirrhosis.

3. Hiatus hernia, uncomplicated.

4. Esophagitis.

FOOTNOTE

Lines 7 (Page 1)-6 (Page 2).  The physician dictates incorrect usage of semicolons and commas several times in the report, and corrections were made in the transcript.

Line 10 (Page 1).  Begun was changed to began to correct grammar.

Line 1 (Page 2).  The diagnoses were enumerated for clarity.

Gastroenterology case study

DISCHARGE SUMMARY

IDENTIFYING DATA

This 72-year-old white female was admitted through the emergency room with coffee-grounds emesis, hemoglobin of 9.5, complaining of left upper quadrant discomfort.

LABORATORY DATA

On admission patient’s hemoglobin was 9.5, white count 8.1, platelet count 208,000, and normal BUN and creatinine.  Urinalysis was normal, serum gastrin levels normal at 43.  Chemistry panel was normal with the exception of a globulin of 1.6, albumin 3.2, total protein 4.8.  Prothrombin time and PTT normal, serum iron 117, and low hemoglobin to 8.5.  Hemoglobin at discharge 10.3.  Chest x-ray reveals no acute process.  Abdominal film nonspecific.

           

HOSPITAL COURSE

Patient was admitted with GI bleed, generally inactive at time of admission in that she had no significant orthostatic changes.  She was placed on IV Zantac, and an emergency endoscopy done showed an erosion at the gastroesophageal junction, a 1.5-cm benign-appearing anterior wall antral ulcer with hemorrhagic speck near its margin, and slight oozing from the margin after endoscopy.  There was moderate antral edema and scarring as well.  The duodenal bulb was scarred as well.

She showed no further signs of active bleeding, but needed
5 units of blood to maintain her hemoglobin greater than 10.

DISCHARGE DIAGNOSES

1. Upper gastrointestinal bleed secondary to gastric ulcer.

2. Anemia secondary to #1.

DISCHARGE MEDICATIONS

Zantac 300 mg q.h.s., Carafate 1 g p.o. t.i.d. 1 hour before meals.

FOOTNOTE

Line 8 (Page 1).  A was added to avoid beginning the sentence with a numeral.

Line 9 (Page 1).  Although coffee-ground emesis was dictated, the correct term is coffee-grounds emesis.

Line 13 (Page 1).  Was added to improve grammar.

Line 15 (Page 1).  The dictated comma after 43 was changed to a period to improve sentence structure.

Line 16 (Page 1).  Chem panel was expanded to chemistry panel.

Line 17 (Page 1).  And was added to separate pro time (prothrombin time) and PTT (partial thromboplastin time).

Line 25 (Page 1).  Alternative:  I.V.

Line 36 (Page 1).  GI was expanded to gastrointestinal in the diagnosis.

Line 39 (Page 1).  Med was expanded to medications.

Gastroenterology case study

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 in the terminal ileum.  My impression was that this could possibly be a Meckel, 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.

FOOTNOTE

Line 13.  Re was not dictated but was added to demonstrate proper letter format.

Gastroenterology case study

HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT

A 55-year-old white female patient who has internal/external hemorrhoids with considerable tissue degeneration at certain gangrenous-appearing sites.  The patient was seen by me the day before yesterday, and then her insurance required a second opinion confirming the pathology.  The patient does have very sore, very painful internal/external hemorrhoids with spots of gangrene.  The patient needs a bowel prep throughout the day today, clear liquids and laxatives, and enemas in the morning, and I plan to schedule her then, in the morning, which is Saturday morning, for a hemorrhoidectomy on an emergency basis.

          

PAST MEDICAL HISTORY

The patient’s past medical history indicates that she has had hemorrhoids for 26 years, but in the past 30 days they got bad and kept getting worse.  The patient is very sore, walks with difficulty, and needs attention to this pathology.

ALLERGIES

SHE IS ALLERGIC TO ASPIRIN, PENICILLIN, AND CODEINE.

MEDICATIONS

She is on Slow-K 1 daily, Saluron 50 mg daily, and Tenormin
1 daily.  The Tenormin is a 50 mg tablet also.

PHYSICAL EXAMINATION

GENERAL:  This lady is rather uncomfortable.

RECTAL:  The patient, on her right side of her anus, has thrombosed, gangrenous internal/external hemorrhoids.  She also has a bunch of skin tags around the rectum from previous problems.  Digital examination is negative beyond the hemorrhoid point.  Proctoscopy done is helpful to identify the pathology.

CONCLUSION AND DISCUSSION

I have discussed with this lady that she needs her surgery.  She has been seen in second opinion; her insurance requires that.  The patient has internal/external hemorrhoids with thrombosis and gangrene.  I am starting her on clear liquids at this moment, laxatives this afternoon, enemas till clear in the morning, and do her at 9 o’clock in the morning.

FOOTNOTE

Lines 9, 10 (Page 1).  The physician dictated with
gangrenous-appearing sites at certain gangrenous-occurring sites.  This was edited to at certain gangrenous-appearing sites.

Line 17 (Page 1).  To correct the redundancy, based on an emergency basis was edited to on an emergency basis.

Line 19 (Page 1).  The heading Past Medical History was added for clarity.

Line 38 (Page 1).  The slang term procto was expanded to proctoscopy.

Gastroenterology Case Study

-->

INITIAL OFFICE EVALUATION

After a trip to Mexico she developed diarrhea which resolved after about 2 months.  However, her stools are now not as firm as before, and she has periodic lighter color of the stools.  Also gets periodic constipation now.

She previously had a bowel movement after supper every night but not since this trip.  Has a 6-month history of nocturia x1 with no history of the same in the past.  Has lost 7 pounds in the past year.  Has a 2- or 3-year history of fatigue which got worse after pneumonia.

         

Blood work demonstrated previous mononucleosis.  CMV was positive.  Thyroid functions were normal.  ASO titer was positive.  Epstein-Barr nuclear antigen was positive at 1:40.  Chemistry profile was normal.  Sedimentation rate normal.  A diagnosis of chronic fatigue syndrome was made.

Over the past fall and winter, she had severe fatigue and achiness in the elbows, knees, ankles, and calves.  The aching has improved but still has considerable fatigue.  She works near where there are numerous foul odors.  Her building is a closed environment without windows.  She took Shaklee vitamins in the past and did have mild to moderate improvement in her symptoms.

MEDICATIONS

None.

PAST MEDICAL HISTORY

Myomectomy for fibroids.  Pneumonia.  Duodenal ulcer which subsequently healed.  Auto accident resulted in problems with the right upper area of the back.

ALLERGIES

SULFA AND ROOT BEER.

REVIEW OF SYSTEMS

Gets sinus headaches and other headaches.  Has lumpy breasts which have been checked by a gynecologist.  Has some indigestion and bloating after meals.  Has some insomnia and gets yeast infections several times a year.

FAMILY HISTORY

Unremarkable.

HABITS

Negative.  Diet balanced and low in sugar.

PHYSICAL EXAMINATION

Examination essentially normal with exception of very slight underweight.

ASSESSMENT

1. Fatigue.

2. Weight loss.

3. Change in bowel habits.

4. Nocturia x1.

5. Positive tests for CMV, ASO titer, and EBNA, with diagnosis of chronic fatigue syndrome.

6. History of pneumonia x2.

7. Possible toxic work environment.

PLAN

In view of her previous response to vitamins, will use recommendations on enclosed note.  Consider elimination diet or basal temperature tests if no improvement.  Return in 6 weeks.

FOOTNOTE

Line 21 (Page 1).  Chem was expanded to chemistry.

Line 4 (Page 2).  Exam was expanded in the title.

Line 13 (Page 2).  The word titer was added for completeness.  Alternative:  Expand the abbreviations, although in an office chart note such as this, it is not necessary.  CMV (cytomegalovirus), EBNP (Epstein-Barr nuclear antigen).

Line 16 (Page 2).  The dictated number 8 was changed to 7 for proper enumeration.