Sample Type / Medical Specialty: Consult - History and Phy.
Sample Name: GI Consultation - 3
Description: GI Consultation for Chrohn's disease.
(Medical Transcription Sample Report)
PROBLEM: Prescription evaluation for Crohn's disease.
HISTORY: This is a 46-year-old male who is here for a refill of Imuran. He is taking it at a dose of 100 mg per day. He is status post resection of the terminal ileum and has experienced intermittent obstructive symptoms for the past several years. In fact, he had an episode three weeks ago in which he was seen at the emergency room after experiencing sudden onset of abdominal pain and vomiting. An x-ray was performed, which showed no signs of obstruction per his report. He thinks that the inciting factor of this incident was too many grapes eaten the day before. He has had similar symptoms suggestive of obstruction when eating oranges or other high-residue fruits in the past. The patient's normal bowel pattern is loose stools and this is unchanged recently. He has not had any rectal bleeding. He asks today about a rope-like vein on his anterior right arm that has been a little tender and enlarged after he was in the emergency room and they had difficulty with IV insertion. He has not had any fever, red streaking up the arm, or enlargement of lymph nodes. The tenderness has now completely resolved.
He had a colonoscopy performed in August of 2003, by Dr. S. An anastomotic stricture was found at the terminal ileum/cecum junction. Dr. S recommended that if the patient experienced crampy abdominal pain or other symptoms of obstruction, that he may consider balloon dilation. No active Crohn's disease was found during the colonoscopy.
Earlier this year, he experienced a non-specific hepatitis with elevation of his liver function tests. At that time he was taking a lot of Tylenol for migraine-type headaches. Under Dr. S's recommendation, he stopped the Imuran for one month and reduced his dose of Tylenol. Since that time his liver enzymes have normalized and he has restarted the Imuran with no problems.
He also reports heartburn that is occurring on a slightly more frequent basis than it has in the past. It used to occur once a week only, but has now increased in frequency to twice a week. He takes over-the-counter H2 blockers as needed, as well as Tums. He associates the onset of his symptoms with eating spicy Mexican food.
PAST MEDICAL HISTORY: Reviewed and unchanged.
ALLERGIES: No known allergies to medications.
ILLNESSES: Crohn's disease, vitamin B12 deficiency.
MEDICATIONS: Imuran, Nascobal, Vicodin p.r.n.
REVIEW OF SYSTEMS: Dated 08/04/04 is reviewed and noted. Please see pertinent GI issues as discussed above. Otherwise unremarkable.
PHYSICAL EXAMINATION: GENERAL: Pleasant male in no acute distress. Well nourished and well developed. SKIN: indurated, cord-like superficial vein on the right anterior forearm, approx. 3 cm in length. Non-tender to palpation. No erythema or red streaking. No edema. LYMPH: No epitrochlear or axillary lymph node enlargement or tenderness on the right side.
DATA REVIEWED: Labs from June 8th and July 19th reviewed. Liver function tests normal with AST 14 and ALT 44. WBCs were slightly low at 4.8. Hemoglobin dropped slightly from 14.1 on 6/8 to 12.9 on 7/19. Hematocrit dropped slightly as well from 43.2 on 6/804 to 40.0 on 7/19/04. These results were reviewed by Dr. S and lab results letter sent.
1. Crohn's disease, status post terminal ileum resection, on Imuran. Intermittent symptoms of bowel obstruction. Last episode three weeks ago.
2. History of non-specific hepatitis while taking high doses of Tylenol. Now resolved.
2. Increased frequency of reflux symptoms.
3. Superficial thrombophlebitis, resolving.
4. Slightly low H&H.
1. We discussed Dr. S's recommendation that the patient undergo balloon dilation for recurrent bowel obstruction type symptoms. The patient emphatically states that he does not want to consider dilation at this time. The patient is strongly encouraged to call us when he does experience any obstructive symptoms, including abdominal pain, nausea, vomiting, or change in bowel habits. He states understanding of this. Advised to maintain low residue diet to avoid obstructions.
2. Continue with liver panel and ABC every month per Dr. S's instructions.
3. Continue Imuran 100 mg per day.
4. Continue to minimize Tylenol use. The patient is wondering if he can take another type of medication for migraines that is not Tylenol or antiinflammatories or aspirin. Dr. S is consulted and agrees that Imitrex is an acceptable alternative for migraine headaches since he does not have advanced liver disease. The patient will make an appointment with his primary care provider to discuss this further.
5. Reviewed the importance of prophylactic treatment of reflux-type symptoms. Encouraged the patient to take over-the-counter H2 blockers on a daily basis to prevent symptoms from occurring. The patient will try this and if he remains symptomatic, then he will call our office and a prescription for Zantac 150 mg per day will be provided. Reviewed the potential need for upper endoscopy should his symptoms continue or become more frequent. He does not want to undergo any type of procedure such as that at this time.
6. His thrombophlebitis appears to be resolving and does not have any alarming features present. No treatment is needed at this time. He is instructed to call our office or his PCP if he experiences any pain, red streaking or fever.
7. We will watch his CBC carefully to ensure that the H&H does not continue to drop. If it does, then he may need further evaluation with iron studies, B12 levels, or a GI evaluation.
FOLLOWUP: Continue liver panel and ABC every month; follow up pending these results. Call our office for obstructive symptoms or continued reflux. Otherwise prescription evaluation in one year.
Keywords: consult - history and phy., gi consultation, crohn's disease, followup:, abdominal pain, balloon dilation, cecum, colonoscopy, enzymes, heartburn, hepatitis, ileum, junction, liver, obstruction, obstructive symptoms, lymph nodes, gi, bowel, disease,