DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Epigastric pain of one-week duration.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old Asian woman who has a history of diabetes mellitus of 20 years’ duration, hypertension, coronary artery disease status post bypass surgery, peripheral vascular occlusive disease status post vascular bypass surgery, and right foot amputation. She was admitted for epigastric pain with bloating of one-week duration. Per the patient, she has been experiencing burning pain in the epigastrium, which is an intermittent pain, which is worse on eating food and an associated bloating sensation in the epigastrium. The bloating is worse especially after eating greasy food and is associated with vomiting. The pain and the bloating are better after she throws up the food. There is no hematemesis. There is no melena.
She is status post cholecystectomy. An ultrasound of the abdomen showed no dilation of the bile duct, and there were no stones in the common bile duct either. The liver function tests, otherwise, were unremarkable. The patient does not take any nonsteroidal anti-inflammatory drugs. She did have an EGD and was found to have arteriovenous malformations in the stomach and the duodenum, with erosive gastritis. Her bowel movements otherwise were regular. There is no blood in the stools. There is no history of recent weight loss.
PAST MEDICAL HISTORY: Significant for diabetes mellitus, hypertension, hypercholesterolemia, coronary artery disease status post bypass surgery, peripheral vascular occlusive disease status post vascular bypass, and right foot amputation.
PAST SURGICAL HISTORY: CABG, cholecystectomy, hysterectomy, vascular bypass surgery in the right lower extremity, and partial amputation of the right foot.
MEDICATIONS: Protonix, insulin, isosorbide, enalapril, Lasix, and Coumadin.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: The patient’s mother and father died of heart disease. She has two brothers and one sister. She is married and has two children.
SOCIAL HISTORY: The patient smoked one pack of cigarettes a day for the last 20 years. She does not drink alcohol. She does not do any injection drugs.
REVIEW OF SYSTEMS: Otherwise negative for other systems.
PHYSICAL EXAMINATION:
GENERAL: The patient is a (XX)-year-old woman who is alert and oriented x3 and comfortable at rest.
VITAL SIGNS: Her vital data includes a temperature of 98.6, heart rate 86, blood pressure 142/82, and respirations 18.
HEENT: Pupils are equal, round, and reacting to light and accommodation. Extraocular movements are intact. ENT examination is normal.
NECK: There is no JVD. There is no lymphadenopathy. There is no thyromegaly. Neck is supple.
HEART: Examination shows first and second heart sounds normally heard. No third sound, fourth sound, and no murmurs.
LUNGS: Auscultation of the lungs show bilateral vesicular breath sounds.
ABDOMEN: Examination of the abdomen shows a distended abdomen secondary to obesity. There is deep tenderness in the epigastrium. There is no hepatosplenomegaly. No ascites. Normal peristaltic sounds are heard.
EXTREMITIES: Extremity examination shows no edema.
SKIN: There is no rash.
NEUROLOGIC: There are no focal neurological deficits.
LABORATORY DATA: The patient had laboratory studies, which show a white cell count of 11.6, hemoglobin 13.4, platelet count 234,000, with MCV of 87.8. Electrolytes: Sodium 136, potassium 4.3, bicarbonate 24, chloride 118, BUN 36, creatinine 1.4, glucose 122. Serum albumin 3.6, total bilirubin 0.4, alkaline phosphatase 87, SGOT 17, and SGPT 22. Protime is 21.3 with an INR of 1.88.
DIAGNOSTIC DATA: Ultrasound of the abdomen shows fatty liver with no dilation of the bile duct. The patient is status post cholecystectomy.
ASSESSMENT AND PLAN:
1. Epigastric pain with a history of diabetes mellitus. The patient also experiences bloating in the abdomen, especially after eating greasy food. Rule out peptic ulcer disease, gastroparesis, gastritis, and esophagitis. The patient was advised to have EGD and gastric emptying scan for further evaluation. The procedure of EGD, including the risks of perforation, bleeding, infection, allergy, and hypotension secondary to sedation, were explained to her in detail and she was willing to have the procedure done on her. The patient will have a gastric emptying scan today. As she is on Coumadin, her Coumadin will be kept on hold today, and we will have the EGD in the morning tomorrow. Continue Protonix now. Further recommendations after the endoscopic and radiological evaluations.
2. Diabetes mellitus, hypertension, coronary artery disease, and hypercholesterolemia. Continue home medication.
