Gastroenterology

CONSULTATION

The patient is a 16-year-old high school student who was referred to “rule out any gastrointestinal problems.  Vomiting occurs as a result of nausea.  This has been going on for about 3-1/2 years.”

This story is complex and complicated.

When the patient turned about 12, she started having nausea and vomiting which began about 4 days before her period.  Her menses were regular until about 6 months ago.  Because of the premenstrual vomiting, she went on Tigan elixir and Donnatal.  This was tried for about 3 months and did not help.  Then she was tried on low doses of birth control pills on a regular basis.  This also did not help much, and she was then switched to Torecan and Pepcid.

Apparently, over the last 6 months her periods have become more irregular.  In addition, she has had vomiting almost every day.  She says that she vomits “phlegm” and sometimes vomits yellow bile which tastes bitter.  She says that she always feels full and does not want to eat.  She has not lost any weight.

She vomits, in addition, if she eats spicy food.  This also results in heartburn, by which she means substernal burning.  Also, if she eats too much she gets the substernal heartburn.  It burns substernally for about 10 minutes.  If she takes the antacid right away, that helps regularly.  The patient herself has had EB (Epstein-Barr) viral infections and also pleurisy.  Past traumas include a sprained wrist, a torn knee cartilage on the left, and an injury to her left eye during a shoe fight at school, which caused temporary impaired vision but no problems at this stage.

She has had pneumonia and bronchitis and often has palpitations.  She says she has a poor appetite, difficulty swallowing foods or liquids, indigestion and heartburn, stomach trouble, gas and bloating, but has no diarrhea or constipation.  She is tired, often feels nervous or upset, and frankly admits to discouragement and depression.  She often has large bruises on her skin and feels that she bleeds or hemorrhages excessively related to her menstrual periods.

SUMMARY, IMPRESSION, AND PLAN

For the past 3 years she has had much vomiting, temporally associated with her menses and definitely worse at the time of her menstrual period.  Nevertheless, she has symptoms suggestive of heartburn and reflux.  A partial problem list at this time would include

1. Vomiting.

2. Heartburn.

3. Recently irregular periods.

4. Mood swings.  She cries a lot, she gets angry over little things, and she throws things.

I cannot really put this all together at this time.  Since she has never had an upper GI x-ray, this appears a reasonable start.

I told the patient and her mother that regardless of any organic disease that she might or might not have, the fact that she frankly admitted depression, was suffering at school because of her schoolwork, and had the vomiting, she needed counseling at least to cope with the problems that she was having.

This entire note was dictated in the presence of the patient and her mother.

FOOTNOTE

Line 16 (Page 1).  Tigan is not available in elixir form, although Tigan is used for control of nausea.  The transcriptionist on the job would seek clarification from the dictator.

Line 33 (Page 1).  EB (not a common abbreviation) was translated for clarity.