I Gastroenterology Consultation Report
Handout Instructions: Below is an item from a patientâs medial record. Read it carefully, make sure you understand all the medical terms used, and then answer the questions that follow. Please follow the instructions given on the email to submit assignment.
Gastroenterology Consultation Report
Reason for Consultation: Evaluation of recurrent epigastric and LUQ pain with anemia.
History of Present Illness: Patient is a 56-year-old male. He reports a long history of mild dyspepsia characterized by burning epigastric pain, especially when his stomach is empty. Over-the-counter antacids have relieved this pain. Approximately two weeks ago, the pain became significantly worse; he is also nauseated and has vomited several times.
Past Medical History: Patientâs history is not significant for other digestive system disorders. He had a tonsillectomy at age 8. He sustained a compound fracture of the left ankle in a bicycle accident at age 11 that required surgical fixation. More recently he has been diagnosed with an enlarged prostate gland, and surgery has been recommended. However, he would like to resolve this epigastric pain before going forward with the TUR.
Results of Physical Exam: CBC indicates anemia, and a fecal occult blood test is positive for blood in the feces. A blood test for Helicobacter pylori is positive. Erosion in the gastric lining was visualized on an upper GI. Follow-up gastroscopy found evidence of mild reflux esophagitis and an ulcerated lesion in the lining of the pyloric section of the stomach. This ulcer is 1.5 cm in diameter and deep. There is evidence of active bleeding from the ulcer. Multiple biopsies were taken, and they were negative for gastric cancer. IV Tagamet relieved the painful symptoms in two days.
Assessment: Peptic ulcer. Gastric cancer has been ruled out in light of the negative biopsies.
Recommendations: A gastrectomy to remove the ulcerated portion of stomach is indicated because the ulcer is already bleeding. Patient should continue on Tagamet to reduce stomach acid. Two medications will be added: Keflex to treat the bacterial infection and iron pills to reverse the anemia. Patient was instructed to eat frequent small meals and avoid alcohol and irritating foods.
This patient reports LUQ pain. What does LUQ stand for and what organs do you find there?
This patient had two diagnostic tests that indicated he was losing blood. Name these two tests (no abbreviations).
This patient had a procedure to visually examine the ulcer. Name the procedure done.
Name the serious pathological condition that was ruled out.
I Gastroenterology Consultation Report
Handout Instructions: Below is an item from a patientâs medial record. Read it carefully, make sure you understand all the medical terms used, and then answer the questions that follow. Please follow the instructions given on the email to submit assignment.
| Gastroenterology Consultation Report |
| Reason for Consultation: Evaluation of recurrent epigastric and LUQ pain with anemia. History of Present Illness: Patient is a 56-year-old male. He reports a long history of mild dyspepsia characterized by burning epigastric pain, especially when his stomach is empty. Over-the-counter antacids have relieved this pain. Approximately two weeks ago, the pain became significantly worse; he is also nauseated and has vomited several times. Past Medical History: Patientâs history is not significant for other digestive system disorders. He had a tonsillectomy at age 8. He sustained a compound fracture of the left ankle in a bicycle accident at age 11 that required surgical fixation. More recently he has been diagnosed with an enlarged prostate gland, and surgery has been recommended. However, he would like to resolve this epigastric pain before going forward with the TUR. Results of Physical Exam: CBC indicates anemia, and a fecal occult blood test is positive for blood in the feces. A blood test for Helicobacter pylori is positive. Erosion in the gastric lining was visualized on an upper GI. Follow-up gastroscopy found evidence of mild reflux esophagitis and an ulcerated lesion in the lining of the pyloric section of the stomach. This ulcer is 1.5 cm in diameter and deep. There is evidence of active bleeding from the ulcer. Multiple biopsies were taken, and they were negative for gastric cancer. IV Tagamet relieved the painful symptoms in two days. Assessment: Peptic ulcer. Gastric cancer has been ruled out in light of the negative biopsies. Recommendations: A gastrectomy to remove the ulcerated portion of stomach is indicated because the ulcer is already bleeding. Patient should continue on Tagamet to reduce stomach acid. Two medications will be added: Keflex to treat the bacterial infection and iron pills to reverse the anemia. Patient was instructed to eat frequent small meals and avoid alcohol and irritating foods. |
| This patient reports LUQ pain. What does LUQ stand for and what organs do you find there? |
| This patient had two diagnostic tests that indicated he was losing blood. Name these two tests (no abbreviations). |
| This patient had a procedure to visually examine the ulcer. Name the procedure done. |
| Name the serious pathological condition that was ruled out. |
