Gastroenterology — New Patient Consultation Template

Consultation Information

Referring physician: [Name, specialty]
Reason for referral: [Chief complaint]
Date of consultation: [Date]
Urgency: Routine / Urgent

Chief Complaint

[Primary GI concern]
Duration: [X] days/weeks/months/years
Current status: Improving / Stable / Worsening

Alarm Symptoms Screening

[ ] Unintentional weight loss (>10% in 6 months)
[ ] GI bleeding (hematemesis, melena, hematochezia)
[ ] Dysphagia (especially progressive solid → liquid)
[ ] Odynophagia
[ ] Persistent vomiting
[ ] Palpable abdominal mass
[ ] Anemia (unexplained iron deficiency)
[ ] Family history of GI malignancy
[ ] Age >50 with new symptoms
Alarm symptoms present: None / [List] — Expedited workup: Yes / No

History of Present Illness

For Abdominal Pain

Location: [Epigastric, RUQ, LUQ, periumbilical, RLQ, LLQ, diffuse]
Character: Crampy / Sharp / Burning / Dull / Colicky
Severity: [X]/10
Radiation: None / [Pattern]
Timing: Constant / Intermittent — Duration of episodes: [X]
Frequency: [Episodes per day/week]
Relation to meals: Before / During / After / [X] hours postprandial / No relation
Aggravating: [Foods, position, activity]
Alleviating: [Antacids, BMs, position, fasting]
Associated: Nausea / Vomiting / Diarrhea / Constipation / Bloating / Distension

For Dyspepsia/Reflux

Heartburn: Yes / No — Frequency: [X]/week
Regurgitation: Yes / No
Dysphagia: None / Solids / Liquids / Both
Globus: Yes / No
Chest pain: Yes / No — Cardiac evaluation: [Status]
Nocturnal symptoms: Yes / No
Laryngeal symptoms: Hoarseness / Cough / Throat clearing
Dietary triggers: [Spicy, fatty, acidic, caffeine, alcohol]
Positional: [Worse supine, bending]
Response to PPIs: [Good, partial, none]

For Nausea/Vomiting

Duration: [Acute, chronic]
Timing: Morning / Postprandial / [X] hours after eating / Any time
Content: Undigested food / Partially digested / Bilious / Bloody
Volume: [Amount]
Associated: Abdominal pain / Early satiety / Weight loss / Gastroparesis risk factors
Triggers: [Foods, medications, position]

For Diarrhea

Duration: [Acute <4 wk, chronic ≥4 wk]
Stool frequency: [X] BMs per day
Consistency: [Bristol type]
Volume: Small / Large volume
Blood: None / Bright red / Maroon / Melena
Mucus: Yes / No
Urgency: Yes / No
Tenesmus: Yes / No
Incontinence: Yes / No
Nocturnal: Yes / No — [Suggests organic cause]
Timing: Constant / Intermittent / Postprandial
Recent: Travel / Antibiotics / Sick contacts / New foods
Associated: Weight loss / Fever / Joint pain / Skin changes

For Constipation

Duration: [Acute, chronic]
Stool frequency: [X] BMs per week
Consistency: [Bristol type]
Straining: Yes / No
Incomplete evacuation: Yes / No
Digital maneuvers: Yes / No
Bloating: Yes / No
Abdominal pain: Yes / No — Relieved with BM: Yes / No
Laxative use: [Types, frequency, response]
Fiber intake: [Adequate, inadequate]
Fluid intake: [Amount]

For GI Bleeding

Type: Hematemesis / Coffee ground / Melena / Bright red blood per rectum
Amount: [Estimate]
Frequency: [Episodes]
Duration: [X] days
Associated: Abdominal pain / Syncope / Lightheadedness / Palpitations
Hemodynamic stability: Stable / Unstable
Recent: NSAIDs / Anticoagulants / Alcohol / Prior bleeding

Bowel Function Review

Baseline frequency: [X] BMs per day/week
Current frequency: [X] BMs per day/week
Bristol stool type: [1-7]
Blood: None / On paper / In toilet / Mixed with stool
Changes in bowel habits: None / [Duration, description]

Diet History

Diet type: Regular / [Restrictions]
Dietary triggers: [Foods causing symptoms]
Fiber intake: Low / Moderate / High
Fluid intake: [Oz/day]
Alcohol: [Type, quantity, frequency]
Caffeine: [Type, quantity]
Artificial sweeteners: [Type]
Recent dietary changes: None / [Description]

Past GI History

Prior GI diagnoses:

• GERD: No / Yes — [Duration, treatment]
• PUD: No / Yes — [H. pylori status]
• IBD: No / Yes — [Type, extent, duration]
• IBS: No / Yes — [Subtype]
• Celiac disease: No / Yes — [Diagnosis date, adherence]
• Diverticulosis/itis: No / Yes — [Complications]
• Polyps: No / Yes — [Type, number, last colonoscopy]
• Liver disease: No / Yes — [Type, stage]
• Pancreatitis: No / Yes — [Etiology, frequency]
• Barrett's esophagus: No / Yes — [Dysplasia status]
• GI malignancy: No / Yes — [Type, treatment]

Prior procedures:

• EGD: [Date, findings]
• Colonoscopy: [Date, findings, polyps]
• ERCP: [Date, indication, findings]
• EUS: [Date, findings]
• Abdominal surgery: [Procedure, date]

H. pylori status: Never tested / Negative / Positive — Treated: Yes / No

Past Medical History

[Relevant conditions, especially:]

• Diabetes: [Duration, neuropathy concerns]
• Thyroid disorders: [Hypo/hyperthyroidism]
• Connective tissue disease: [Scleroderma, etc.]
• Cardiac disease: [Anticoagulation needs]
• Renal disease: [CKD stage]
• Neurological: [Parkinson's, MS]

Surgical History

Abdominal surgeries: None / [Procedure, date]

• Cholecystectomy: No / Yes — [Date]
• Appendectomy: No / Yes — [Date]
• Bariatric surgery: No / Yes — [Type, date]
• Bowel resection: No / Yes — [Reason, extent]
• Hernia repair: No / Yes — [Type, date]

Medications

Current GI medications:

• PPIs: [Drug, dose, duration]
• H2 blockers: [Drug, dose]
• Antacids: [Frequency]
• Laxatives: [Type, frequency]
• Anti-diarrheals: [Type, frequency]
• Antispasmodics: [Drug, dose]
• 5-ASA: [Drug, dose]
• Biologics: [Drug, dose, frequency]

Other relevant medications:

• NSAIDs: [Drug, frequency] — [GI risk]
• Anticoagulants: [Drug, dose]
• Opioids: [Drug, dose] — [Constipation]
• Antibiotics recent: [Drug, duration]

Allergies

[Drug allergies with reactions]
Contrast allergy: No / Yes — [Reaction, premedication]

Family History

Colon cancer: No / Yes — [Relationship, age at diagnosis]
Colon polyps: No / Yes — [Relationship, type]
IBD: No / Yes — [Relationship, type]
Celiac disease: No / Yes — [Relationship]
GI malignancy other: No / Yes — [Type, relationship]
Liver disease: No / Yes — [Type, relationship]
Pancreatic disease: No / Yes — [Relationship]

Social History

Tobacco: Current / Former / Never — Pack-years: [X]
Alcohol: [Type, quantity, frequency]

• History of heavy use: No / Yes

Recreational drugs: None / [Types]
Occupation: [GI exposures]
Travel: Recent [Location] / None
Stress level: Low / Moderate / High

Review of Systems

Constitutional: [ ] Weight loss ([X] lbs) [ ] Fatigue [ ] Fever [ ] Night sweats
Skin: [ ] Jaundice [ ] Rash [ ] Pruritus
HEENT: [ ] Mouth sores [ ] Dysphagia
Cardiovascular: [ ] Chest pain [ ] Palpitations
Respiratory: [ ] Cough [ ] Dyspnea
GI: [As above in HPI]
GU: [ ] Dysuria [ ] Hematuria
MSK: [ ] Joint pain [ ] Back pain
Neuro: [ ] Numbness [ ] Weakness
Psych: [ ] Depression [ ] Anxiety

Physical Examination

Vital Signs

BP: [X/X]
HR: [X]
RR: [X]
Temp: [X]°F
Weight: [X] — BMI: [X]
Recent weight change: None / [+/- X lbs over X time]

General

Appearance: Well-nourished / Thin / [Cachectic]
Distress: None / [Mild, moderate, severe]
Hydration: Adequate / [Signs of dehydration]

HEENT

Sclera: Anicteric / Icteric
Oral: Moist / Dry / [Lesions, ulcers]
Dentition: Good / Poor
Thyroid: Normal / [Enlarged]

Cardiovascular

Rhythm: Regular / [Irregular]
Murmurs: None / [Description]

Pulmonary

Breath sounds: Clear / [Findings]

Abdominal

Inspection:

• Contour: Flat / Scaphoid / Distended
• Scars: None / [Location]
• Visible masses: None / [Location]
• Visible peristalsis: No / Yes
• Caput medusae: No / Yes

Auscultation:

• Bowel sounds: Normal / Hyperactive / Hypoactive / Absent
• Bruits: None / [Location]

Percussion:

• Tympany: Present / [Dullness]
• Liver span: [X] cm MCL
• Shifting dullness: Absent / Present
• Fluid wave: Absent / Present

Palpation:

• Soft / Firm / Rigid
• Tenderness: None / [Location, severity]
• Guarding: None / Voluntary / Involuntary
• Rebound: Absent / Present
• Murphy's sign: Negative / Positive
• McBurney's point: Non-tender / Tender
• Hepatomegaly: No / Yes — [X] cm below RCM
• Splenomegaly: No / Yes — [X] cm below LCM
• Masses: None / [Location, size, characteristics]

Rectal (if indicated)

Deferred / Performed:

• Sphincter tone: Normal / [Increased, decreased]
• Masses: None / [Description]
• Stool: Brown / [Melena, bright blood]
• Guaiac: Negative / Positive
• Prostate (male): Normal / [Enlarged, nodular]

Skin

Jaundice: Absent / Present
Spider angiomata: Absent / Present
Palmar erythema: Absent / Present
Peripheral edema: Absent / Present — [Grade]

Lymph Nodes

Cervical/axillary/inguinal: Not enlarged / [Enlarged]

Diagnostic Studies Review

Laboratory

CBC: [Values]
CMP: [Values]
LFTs: [AST, ALT, Alk phos, Bili, Albumin]
Lipase: [If applicable]
Celiac panel: [If applicable]
H. pylori: [Stool Ag, breath test, serology]
Iron studies: [If applicable]
Inflammatory markers: [ESR, CRP, Calprotectin]

Stool Studies

Calprotectin: [Value]
C. diff: [Result]
Stool culture: [Result]
Ova and parasites: [Result]
Fat (quantitative): [If applicable]

Imaging

Abdominal ultrasound: [Date, findings]
CT abdomen/pelvis: [Date, findings]
MRI/MRCP: [Date, findings]
Barium studies: [Date, findings]

Prior Endoscopy

EGD: [Date, findings, biopsies]
Colonoscopy: [Date, findings, polyps, biopsies]

Assessment

1) [Primary GI diagnosis]
Severity: [Mild, moderate, severe]
Duration: [Acute, chronic]
2) [Secondary diagnoses]
3) [Screening needs - colonoscopy, etc.]
Differential diagnosis:

• [Most likely]
• [Alternative 1]
• [Alternative 2]

Plan

Diagnostic Workup

Laboratory:

• [ ] CBC, CMP, LFTs
• [ ] Celiac panel (TTG IgA, total IgA)
• [ ] H. pylori [stool Ag / breath test]
• [ ] Fecal calprotectin
• [ ] Stool studies: [Culture, O&P, C. diff]
• [ ] Iron studies
• [ ] Thyroid function
• [ ] Other: [Specific tests]

Imaging:

• [ ] Abdominal ultrasound
• [ ] CT abdomen/pelvis
• [ ] MRI/MRCP
• [ ] Gastric emptying study
• [ ] Other: [Specific]

Endoscopy:

• [ ] EGD — Indication: [X]

Biopsies: [Esophageal, gastric, duodenal]
H. pylori testing: Yes / No

• [ ] Colonoscopy — Indication: [X]

Prep: [Type]
Biopsies: [Random, targeted]

• [ ] EUS — Indication: [X]
• [ ] Capsule endoscopy — Indication: [X]
• [ ] Flex sig — Indication: [X]

Scheduling: [Routine, urgent, inpatient]

Treatment

Lifestyle Modifications:

• Diet: [Specific recommendations]
• Fiber: [Increase/supplement]
• Fluids: [Goal]
• Weight management: [If applicable]
• Avoid: [Triggers, NSAIDs, alcohol]

Medications:

• [New medication, dose, duration]
• [Adjustment to current medications]

Referrals

• [ ] Hepatology
• [ ] Nutrition/dietitian
• [ ] Surgery
• [ ] Oncology
• [ ] Other: [Specify]

Patient Education

• Diagnosis explanation
• Dietary instructions
• Medication instructions
• Procedure preparation (if scheduled)
• Warning signs requiring urgent evaluation

Follow-up

Return: [X] weeks for [Results, response to treatment]
Sooner if: [Alarm symptoms, worsening]
Phone results: [Yes/No]

Communication

Discussed with patient: [Topics]
Report sent to: [Referring physician, PCP]