MMC GI Initial Consult Note v2

***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:
[checkbox value="None @ MMC"]
[textarea name="variable_7" default=""]

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

Medications:
***

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

Family history:
[checkbox value="Unknown|Non-contributory|No known history of gastrointestinal malignancies in 1st degree relatives|No known history of hepatobiliary malignancies in 1st degree relatives|No known history of gastrointestinal/hepatobiliary malignancies in 1st degree relatives"]

***OBJECTIVE:***
Vital signs:
***

Physical examination:
[checkbox name="Problem4999" value="Normal Physical Exam"] [conditional field="Problem4999" condition="(Problem4999).is('Normal Physical Exam')"] 
GENERAL: adult patient, laying in bed, in no acute distress
HEENT: normocephalic, atraumatic, PERRL, EOMI
CV: RRR, +s1/s2
RESP: +breath sounds b/l
ABD: soft, non-tender, non-distended, +bowel sounds
EXTREMITIES: no peripheral edema
NEURO: no focal deficits discernible on observation
PSYCH: normal mood and affect
 [/conditional]
[checkbox name="Problem400" value="GENERAL:"] [conditional field="Problem400" condition="(Problem400).is('GENERAL:')"] [checkbox value="Well-groomed, well-appearing patient, in no acute distress|Pediatric|Adult|Elderly|male patient|female patient|laying in bed|sitting at bedside|up in chair|well-groomed|well-appearing|chronically-ill in appearance|acutely ill in appearance|appears uncomfortable|appears in pain|toxic in appearance|in moderate distress|in no acute distress"]. [textarea name="gen" default=""][/conditional]
[checkbox name="Problem401" value="SKIN:"] [conditional field="Problem401" condition="(Problem401).is('SKIN:')"] [checkbox value="Warm, dry and intact. Color appropriate for ethnicity|Warm|Cool|Cold|dry|clammy|diaphoretic|color appropriate for ethnicity|pale"]. [textarea name="skin" default=""][/conditional]
[checkbox name="Problem402" value="HEENT:"] [conditional field="Problem402" condition="(Problem402).is('HEENT:')"] [checkbox value="Normocephalic, atraumatic|PERRL|no lymphadenopathy|trachea midline|oral os without edema or erythema|no JVD"]. [textarea name="head" default=""][/conditional]
[checkbox name="Problem403" value="RESP:"] [conditional field="Problem403" condition="(Problem403).is('RESP:')"] [checkbox value="Symmetrical with equal breath sounds. Clear to auscultation bilaterally|speaking in full sentences|diminished lung bases| wheezing|rhonchi|rales|tachypneic|nasal flaring|on RA|on supp O2 per NC|on HFNC|on mask|on BiPAP|intubated"]. [textarea name="resp" default=""][/conditional]
[checkbox name="Problem404" value="CARD:"] [conditional field="Problem404" condition="(Problem404).is('CARD:')"] [checkbox value="Regular rate and rhythm without murmurs, clicks or rubs|reg rate|reg rhythm|irregular rhythm|Grade I murmur best heard over apex|Grade II murmur best heard over apex|Grade III murmur best heard over apex|tachycardic|no significant abnormalities on telemetry|no significant abnormalities on 12-lead EKG|no BLE edema"]. [textarea name="card" default=""][/conditional]
[checkbox name="Problem405" value="GI/GU:"] [conditional field="Problem405" condition="(Problem405).is('GI/GU:')"] [checkbox value="Soft, non-tender and non-distended. Normal bowel sounds|soft|non-tender|non-distended|bowel sounds normal|bowel sounds hypoactive|bowel sounds hyperactive|bowel sounds absent|epigastric tenderness|RUQ tenderness|LUQ tenderness|RLQ tenderness|LLQ tenderness|suprapubic tenderness|right CVA tenderness|left CVA tenderness|distended|peritoneal signs present|foley catheter in place"]. [textarea name="abd" default=""][/conditional]
[checkbox name="Problem406" value="MS:"] [conditional field="Problem406" condition="(Problem406).is('MS:')"] [checkbox value="FROM to BUE|FROM to BLE|normal muscle bulk and tone|gait even and steady"]. [textarea name="ms" default=""][/conditional]
[checkbox name="Problem407" value="EXT:"] [conditional field="Problem407" condition="(Problem407).is('EXT:')"] [checkbox value="No edema to BLE, PPP, no clubbing or cyanosis|edema noted|venous stasis dermatitis to BLE|surgical extremity immobilized with sling|patient in hip precations|CMS intact to surgical extremity|surgical dressing is CDI|JP drain in place|draining sanguineous fluid|draining serous fluid|draining serosanguinous fluid|with no drainage"]. [textarea name="ext" default=""][/conditional]
[checkbox name="Problem408" value="NEURO:"] [conditional field="Problem408" condition="(Problem408).is('NEURO:')"] [checkbox value="Alert and oriented x 3, speech clear. No focal findings present|Alert|oriented to self|oriented to place|oriented to time|confusion noted|delirious|obtunded|somnolent|patient is at mental baseline|Cannot assess as pt is intubated|"]. [textarea name="neuro" default=""][/conditional] 
[checkbox name="Problem409" value="PSYCH:"] [conditional field="Problem409" condition="(Problem409).is('PSYCH:')"] [checkbox value="Normal mood and affect|tearful|appears anxious|physically combative|verbally combative|flat affect|denies SI|endorses SI|Cannot assess as pt is intubated"]. [textarea name="psych" default=""][/conditional]

Labs:
***

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

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

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

The case was discussed w/ the [checkbox value="consult|on-call"] attending, Dr. [checkbox value="Linda Lee, MD|Yuriy Tsirlin, MD|Seth Lapin, DO|Michael Kantrowitz, DO|Dmitriy Khodorskiy, MD|Negar Niknam, MD|Elliot Fuhrer, MD|Ira Mayer, MD|Ronnie Porat Jankelson, MD|Aaron Tokayer, MD|James Park, MD"].

Tanuj Chokshi, DO
Gastroenterology & Hepatology Fellow
p6315