[doctor] patrick allen . date of birth : 7/7/1977 . new patient visit . past medical history includes gerd , anxiety , depression . here for chronic abdominal pain . he had an abdominal ct on 1/23/2020 . impression is a normal ct of the ab- abdomen .
[doctor] hello , are you mr. allen ?
[patient] yes , i am .
[doctor] hi . my name is dr. edwards . nice to meet you .
[patient] nice to meet you .
[doctor] welcome to the gi specialty clinic .
[patient] thank you .
[doctor] did you have any problems finding us ?
[patient] no , i've been here with my sister once before .
[doctor] good . so how can i help you today ? uh , the referral i have is for abdominal pain and diarrhea .
[patient] right . so i've had ... i've been having this pain right here in my stomach , like right around here .
[doctor] so in the area of your mid abdomen , just below the belly button ?
[patient] correct . i've had the pain on and off for about two years . i finally went to the er and a ... a few months ago and they did a ct scan .
[doctor] i saw that .
[patient] yeah . they said they did n't really see anything on the scan .
[doctor] yes , i agree . it looked normal .
[patient] the problem is i'm either constipated or have explosive diarrhea .
[doctor] is the pain there all the time ?
[patient] it's a nagging feeling and it just depends . sometimes it bothers me , sometimes it does n't .
[doctor] has this been the case over the past two years as well ?
[patient] more recently in the past couple months , at least with the constipation and diarrhea .
[doctor] and before that , how are your bowel movements ?
[patient] they were normal .
[doctor] uh , okay . so any blood in your stool ?
[patient] nope .
[doctor] do you feel like you have more constipation or diarrhea ?
[patient] probably more constipation .
[doctor] okay , so when you're constipated , do you not have a bowel movement or is the stool hard ?
[patient] i usually do n't go , but when i do , it's hard .
[doctor] and how often do you have a bowel movement when you are constipated ?
[patient] about three to four times a week . it's like when i need to go to the bathroom , if i can massage it , it feels like it's moving some and i can eventually go .
[doctor] okay . and when you have a bowel movement , does the pain change ?
[patient] yeah , it gets a little better .
[doctor] and are you eating and drinking okay ? any nausea or vomiting , heartburn or indigestion ?
[patient] none of that .
[doctor] okay . so tell me about the diarrhea , how often do you get it ?
[patient] it kinda just depends on what i eat . i think i have a very sensitive stomach . if i eat pasta with a creamy sauce , i'm probably gon na have diarrhea .
[doctor] okay . and it does n't happen for multiple days in a row or is it just one time ?
[patient] it's usually just one time and then it's over .
[doctor] and how's your weight been ? any fluctuation ?
[patient] nice and pretty stable , although i could stand to lose about 25 pounds .
[doctor] okay . and is there any family history of gi issues that you know of ?
[patient] not that i can think of . well , actually my sister does have problems with her stomach too . she has irritable bowel syndrome and that is kind of what i always thought i had even thought i've never been diagnosed with it .
[doctor] okay . and is there any family history of gi cancer or liver disease ?
[patient] nope .
[doctor] have you ever had any surgeries on your abdomen ?
[patient] i've never had any surgery .
[doctor] okay , so your gallbladder , appendix , all those are still intact ?
[patient] yup .
[doctor] and have you ever had a colonoscopy ?
[patient] no . i thought that happen when you turn 50 .
[doctor] well , that's for colon cancer screening , but there are other reasons to have a colonoscopy , like unexplained abdominal pain and changes in bowel habits .
[patient] okay .
[doctor] well , come have a seat here and lay back so i can examine you .
[patient] okay .
[doctor] i'm gon na start by listening to your belly with my steth- stethoscope . and i hear bowel sounds in all four quadrants .
[patient] what does that mean ? is everything okay ?
[doctor] it just means that i can hear little noises in all areas of your belly , which means your bowels are active and working .
[patient] okay , good .
[doctor] so now , i'm going to push on your upper and lower abdomen . let me know if you have any pain .
[patient] it hurts a little when you push right there on the left side , near my belly button .
[doctor] okay . i do feel stool in your lower colon , which would coincide with constipation , but i also feel a slight enlargement of your liver here on the upper right side . have you had any lab work done recently ?
[patient] yes , i have a physical about four months ago and they ... i had blood drawn then .
[doctor] okay . and did your primary care physician say anything about the lab results ?
[patient] he said i had some very slightly elevated liver enzymes , but we would recheck them in about six months .
[doctor] and you remember what enzymes were elevated , alt , ast , alp ?
[patient] he said the alt and the ast were elevated .
[doctor] and do you take any medications , either prescription or over-the-counter ?
[patient] i take crestor and olmesartan daily and then tylenol for occasion- occasional pain .
[doctor] and how frequently do you take the tylenol ?
[patient] hardly ever . maybe once a month .
[doctor] and do you consume alcohol ?
[patient] uh , yes , but only a couple of beers after working in the yard on saturdays .
[doctor] okay . and no previous history of heavy alcohol or drug use ?
[patient] nope .
[doctor] and have you had any recent issues with excessive bruising or bleeding ?
[patient] nope .
[doctor] and how about any issues with your ankles or feet swelling ?
[patient] no .
[doctor] okay . i'm gon na take a look at your eyes and skin . i do n't see any jaundice .
[patient] what would cause that ?
[doctor] issues with your liver . let me take a quick listen to your heart and lungs .
[patient] okay .
[doctor] lungs are clear , bilateral heart sounds are normal , no murmurs , gallops , or rubs noted .
[patient] that's good .
[doctor] yes . the rest of your physical exam is normal other than what seems to be an increased stool burden in your colon and a slight hepatomegaly .
[patient] what's that ?
[doctor] increase stool burden means that there's a lot of stool sitting in your colon .
[patient] and that's the constipation , right ? but what about the other thing ?
[doctor] the hepatomegaly means the liver is enlarged .
[patient] but you said mine was slightly enlarged ?
[doctor] correct .
[patient] so what does that mean ?
[doctor] well , let's talk about what we found and then some possible next steps if you're in agreement .
[patient] okay .
[doctor] so as i said , the hepatomegaly means your liver is enlarged .
[patient] could that be why my stomach is hurting and i'm having issues with the constipation and diarrhea ?
[doctor] no , i think you're constipated and have occasional bouts of diarrhea because of certain foods you eat . and we can get you started right away on a fiber supplement that should help with that .
[patient] so what about my liver ? why is it enlarged ?
[doctor] well , there are many reasons why people can have an elevated liver enzymes and also enlarged liver . some possible causes are certain medications that can be toxic to liver , alcohol abuse , fatty liver disease , hepatitis , cirrhosis , and other liver diseases like wilson's disease .
[patient] so what do i need to do ?
[doctor] well , i think since it's been about four months since your blood work was done , we should check your liver enzymes in addition to a few other labs .
[patient] okay . and then what ?
[doctor] we will get those drawn today and then depending upon the results you may need an ultrasound of your liver . i think we need to talk about your medications too .
[patient] which medications ?
[doctor] crestor , how long have you been taking that ?
[patient] about 18 months .
[doctor] okay . well , crestor is one of the medications that can cause liver toxicity so it may be a good idea to discuss other alternatives .
[patient] should i talk to my primary care or can you change it ?
[doctor] i would recommend calling your primary care and discuss that with him since he follows you for your blood pressure and cholesterol .
[patient] okay . i'll call him this afternoon .
[doctor] great . i also think we should go ahead and get you scheduled for a liver ultrasound . if your blood work looks good , then we can always cancel that .
[patient] okay . when do you think i'll be able to get the ultrasound done ?
[doctor] hopefully , within the next two weeks . you will receive a call from the radiology scheduling this afternoon to get it set up .
[patient] okay . and then what happens ?
[doctor] when i get the results from the test , i will contact you . and depending upon what we find , we'll come up with our next steps .
[patient] and when should i see you again ?
[doctor] uh , let's schedule an appointment when you check out to return in four weeks . we'll discuss how you're doing with the fiber supplement and your constipation and review test results to determine if we need to do further testing on your liver .
[patient] okay . is there anything else i can do to help with these issues ?
[doctor] definitely refrain from drinking any alcohol , increase your water intake to at least 48 ounces a day in addition to taking the fiber supplement to help with your constipation . and be mindful of eating foods that you were sensitive to so you can avoid the bouts of diarrhea .
[patient] okay . and i'll talk to my primary care about my crestor .
[doctor] excellent . and do you have any other questions for me ?
[patient] i do n't think so .
[doctor] great . so remember when you check out the front desk , schedule follow-up appointment with me for four weeks and then go to the lab to get your blood work drawn .
[patient] okay . sounds good .
[doctor] and expect a call from radiology scheduling about setting up your ultrasound .
[patient] all right . thanks , dr. edwards .
[doctor] thank you , mr. allen .

Medical orders:
description: liver ultrasound of your liver
order_type: imaging
reason: depending upon the results
description: schedule an appointment four weeks
order_type: followup
reason: constipation review test results to determine if we need to do further testing on your liver
description: fiber supplement
order_type: medication
reason: constipation
description: blood liver enzymes today
order_type: lab
reason: slight hepatomegaly