MMC – GI Initial Consult Note

[date name="variable_1" default="08-24-2022"]

***SUBJECTIVE:***
Reason for consult: [text name="variable_2" default=""]
History of present illness:
[textarea name="variable_3" default=""]

Review of systems:
[textarea name="variable_4" default="General:denies fever/chills, fatigue, malaise, weight changes
HEENT:denies headaches, vision changes, rhinorrhea, sore throat
Cardiac:denies chest pain, palpitations, peripheral edema
Pulmonary:denies shortness of breath, dyspnea, cough, sputum production
GI:denies nausea/vomiting, abdominal pain, diarrhea/constipation, melena/hematochezia
GU:denies dysuria, hematuria
MSK:denies myalgias, arthralgias, weakness, numbness/tingling
Dermatologic:denies rashes
Neurologic:denies seizures
Hematologic/lymphatic:denies abnormal bleeding/bruising"]

Past medical/surgical history:
[textarea name="variable_5" default=""]

Past endoscopic history:
[textarea name="variable_7" default=""]

Allergies:
[textarea name="variable_8" default=""]

Medications:
[textarea name="variable_9" default=""]

Social history:
[textarea name="variable_10" default="Tobacco: denies
Alcohol: denies
Illicit drugs: denies"]

Family history:
[textarea name="variable_11" default=""]

***OBJECTIVE:***
Vital signs:
[textarea name="variable_18" default=""]

Physical examination:
[textarea name="variable_12" default="General:AAOx3, NAD
HEENT:NC/AT, PERRLA, EOMI
Cardiovascular:RRR, +s1, +s2
Pulmonary:CTA b/l, no W/R/R
Abdominal:soft, NT/ND, +bowel sounds
Neurological/MSK/Extremities:No gross deficits discernible on observation"]

Labs:
[textarea name="variable_13" default=""]

Radiology:
[textarea name="variable_14" default=""]

***ASSESSMENT/SUMMARY:***
[textarea name="variable_15" default=""]

***RECOMMENDATIONS:***
[textarea name="variable_16" default=""]

Case discussed w/ attending, Dr. [text name="variable_17" default=""].

Tanuj Chokshi, DO
Gastroenterology Fellow
p6315