Medical Specialty:
Consult - History and Phy.

Sample Name: GI Consultation - 1

Description: GI Consultation due to rectal bleeding, positive celiac sprue panel
(Medical Transcription Sample Report)

PROBLEM: Rectal bleeding, positive celiac sprue panel.

HISTORY: The patient is a 19-year-old Irish-Greek female who ever since elementary school has noted diarrhea, constipation, cramping, nausea, vomiting, bloating, belching, abdominal discomfort, change in bowel habits. She noted that her symptoms were getting increasingly worse and so she went for evaluation and was finally tested for celiac sprue and found to have a positive tissue transglutaminase as well as antiendomysial antibody. She has been on a gluten-free diet for approximately one week now and her symptoms are remarkably improved. She actually has none of these symptoms since starting her gluten-free diet. She has noted intermittent rectal bleeding with constipation, on the toilet tissue. She feels remarkably better after starting a gluten-free diet.

ALLERGIES: No known drug allergies.

OPERATIONS: She is status post a tonsillectomy as well as ear tubes.

ILLNESSES: Questionable kidney stone.


HABITS: No tobacco. No ethanol.

SOCIAL HISTORY: She lives by herself. She currently works in a dental office.

FAMILY HISTORY: Notable for a mother who is in good health, a father who has joint problems and questionable celiac disease as well. She has two sisters and one brother. One sister interestingly has inflammatory arthritis.

REVIEW OF SYSTEMS: Notable for fever, fatigue, blurred vision, rash and itching; her GI symptoms that were discussed in the HPI are actually resolved in that she started the gluten-free diet. She also notes headaches, anxiety, heat and cold intolerance, excessive thirst and urination. Please see symptoms summary sheet dated April 18, 2005.

PHYSICAL EXAMINATION: GENERAL: She is a well-developed pleasant 19 female. She has a blood pressure of 120/80, a pulse of 70, she weighs 170 pounds. She has anicteric sclerae. Pink conjunctivae. PERRLA. ENT: MMM. NECK: Supple. LUNGS: Clear to auscultation. HEART: Regular rate and rhythm. ABDOMEN: Soft, nondistended and nontender. Good bowel sounds. RECTAL: She has no external hemorrhoids and no probable internal hemorrhoids on exam. LYMPH: No cervical lymphadenopathy. EXTREMITIES: No edema. No rash. NEURO/PSYCH: Orientation, memory, motor and gait are intact.

IMPRESSION/PLAN: The patient is a 19-year-old female with what appears to be celiac sprue, that is markedly improved on a gluten-free diet. I discussed with her and her mother that the gold standard really is a small bowel biopsy, but she would have to go back on her gluten diet to obtain the study. At this point in time, she does not seem to be quite interested in that as she feels to be markedly better for the first time in many years. I have given her a handout regarding celiac disease as well as a gluten-free diet and we will go ahead and obtain a small bowel follow through as it seems as if she has had symptoms for many years. We will check a TSH as well as a CBC to make sure she is not anemic and secondary to the rectal bleeding and a sister with inflammatory arthritis, we will go ahead and check a flexible sigmoidoscopy to make sure there are no signs of inflammatory bowel disease.

Keywords: consult - history and phy., bleeding, abdominal discomfort, belching, bloating, bowel, celiac sprue, change in bowel habits, constipation, cramping, diarrhea, gluten-free, nausea, rectal, vomiting, inflammatory arthritis, rectal bleeding, gi, inflammatory, sprue, celiac, gluten, diet,