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.

Gastroenterology case study

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 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.

FOOTNOTE

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

Line 20.  C. difficile (Clostridium difficile).

Line 27.  The apostrophe was removed even though dictated.  Alternatively you can use the full term, i.e., Crohn disease.

Gastroenterology Case Study

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 in 45 minutes.  No dilated loops were observed at the time the 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 to 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

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 childhood.  However, she does have maturity-onset diabetes.  The transit time through the small bowel was not slowed, which lessens 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 Lomotil 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 a serum ionized calcium.  Other tests as suggested above will depend more upon how the clinical picture develops in the near future.

FOOTNOTE

Line 33 (Page 1).  Is was changed to are for correct subject-verb agreement.

Line 44 (Page 1).  The inappropriate comma was deleted.  Alternative:  T-8, T-12.

Lines 12, 13 (Page 2).  TIA and CNS were expanded in the Differential Diagnosis for clarity.

Gastroenterology studies

CONSULTATION

He received multiple transfusions for his multiple vascular surgeries.  There was no history of any jaundice following any of these transfusions, although he relates some jaundice many, many years ago with the etiology at that time being unclear.  He has manifested no symptoms referable to liver disease and generally remains asymptomatic in this regard.  There is no history of significant alcohol intake, recent travel, and the only drug one could implicate in his hepatitis is Aldomet, which he has been on for only 1 year.

His physical examination revealed that his liver extended 3 to
4 fingerbreadths below his right costal margin and was firm; however, no other signs of liver disease, namely, spider angiomata or palmar erythema were present.  We have found that his SGOT was elevated at least as far back as February.  Several repeat blood tests have shown varying degrees of elevation of the bilirubin and transaminases.  Additionally, his globulins have been elevated, and his prothrombin time has been mildly prolonged to approximately 50% of control.

It seems likely that Mr. (blank) has chronic liver disease from his transfusions in the 1970s, the etiology being non-A non-B.  It is unlikely that Aldomet is contributing to his elevated transaminases as the elevations have been documented prior to the Aldomet usage.  The possible chronic liver diseases include chronic persistent hepatitis, chronic active hepatitis, and the possible development of cirrhosis.  I am concerned about the development of cirrhosis in view of the prolonged prothrombin time and the elevated globulin level, although one cannot be sure regarding this diagnosis without a liver biopsy.  In view of his mild enzyme elevations, his asymptomatic state in regard to his liver disease, despite a liver biopsy showing chronic active hepatitis, I could not imagine treating him with immunosuppressive therapy in view of his age and general medical condition.  Additionally, it is still unknown at this time what the natural history of this disease is, as well as whether there is any significant response to steroid therapy in terms of prognosis.  As well, with his mildly prolonged prothrombin time, this would pose a slightly increased risk of the liver biopsy that at this time I do not feel is warranted in view of the unlikelihood of any treatment based on the liver biopsy findings.

We will simply watch him and have repeat liver tests in approximately 3 months.  Should the disease progress in any way or he become symptomatic or new data become available on the use of steroids in the treatment of non-A non-B chronic liver disease, then we may reassess the need for the liver biopsy at that time.

FOOTNOTE

Lines 17, 18 (Page 1).  Alternative:  3-4.

Line 18 (Page 1).  The comma dictated before the however clause was changed to a semicolon to correct the punctuation error.  To reduce the awkwardness of the sentence, the connector or was inserted between angiomata and palmar.

Lines 24, 34, 35, 44 (Page 1).  The brief form pro time (written as 2 words) was dictated and is expanded to prothrombin time.

Line 28 (Page 1).  The dictated period was changed to a comma for correct punctuation.

Line 37 (Page 1).  Regards (meaning sentiments) was changed to regard (meaning concerning).