Gastroenterology Case Study

CHART NOTE

The patient had severe constipation.  Therapeutically I recommended a high-fiber diet.  She was also given psyllium and instructed to exercise regularly.  If the above regimen fails, I would consider using lactulose and proceeding with flexible sigmoidoscopy.

CHART NOTE

The patient has 1 small colonic polyp with a history of
(1) Hemoccult-positive stools, (2) fatigue, and (3) a URI.  My recommendations are that the patient be started on a high-fiber diet.  He should exercise regularly.  I ordered a Westergren sedimentation rate, and the result was 31 (this is slightly high, with the upper limit of normal being 20).  I gave him erythromycin for his URI.  On return visit, I would strongly consider performing a colonoscopy and possibly a polypectomy.

CHART NOTE

Patient has primary biliary cirrhosis.  I refilled the patient’s colchicine.  Articles were sent to the patient on primary biliary cirrhosis.  The patient should have LFTs and a serum cholesterol drawn every 8 months.  I ordered a chemistry-25, CBC, iron, and TIBC.  The results of these tests were within normal limits with the following important exceptions:  Serum iron was 45, which is low.  TIBC was 433, which is high; and percent iron saturation was 10, which is low.  Her ferritin was 10, which is also low.  These results taken together indicate that the patient was iron deficient, and so I started her on Feosol 1 p.o. b.i.d.  Her GGT was 105, which is elevated.  An alkaline phosphatase was 209, which is also elevated.  A CT scan of the abdomen had been done and was negative.

She continued to have abdominal pain, and I gave her a trial of Reglan 10 mg p.o. q.i.d., and also scheduled an upper

GI/small-bowel follow-through.  The upper GI showed hesitancy in opening of the duodenal bulb, but the bulb was intrinsically normal, and the duodenum was normal as well.  The remainder of the upper GI series and small bowel series was normal.  I do not believe the hesitancy in the opening of the duodenal bulb to be significant.

I saw the patient again with continued complaints of abdominal pain.  At that time her friend had just died of colon cancer.  She complained of fatigue and malaise as well as new symptoms of reflux and heartburn.

My impression is that she has irritable bowel syndrome as well as esophageal reflux.  I gave her a prescription of Sinequan 25 mg q.d. and a sample supply of Tagamet 400 mg b.i.d.  The Tagamet improved her symptoms as she called in for a refill.

FOOTNOTE

Line 8 (Page 1).  When a physician dictates a drug that is listed as both generic and trade name (e.g., psyllium, Cillium), select the generic if the physician’s preference is unknown.

Line 17 (Page 1).  The numeral l was supplied for consistency in enumeration.

Line 31 (Page 1).  It is preferable to not mix Latin and English terms together.  So q.8 months dictated was changed to every
8 months.

Line 31 (Page 1).  Chem-25 was expanded to chemistry-25 (meaning 25 blood chemistry studies were ordered from a single blood sample.)

Line 38 (Page 1).  Alk phos was expanded to alkaline phosphatase.