Physician's Assistant

Endoscopy report Tue 16 December 2025 14:46

Last Modified: 111 days ago

MRN:

Content:

GASTROENTEROLOGY CONSULTATION

Patient: Victor Morgan
MRN: 322915
Date: 16/12/2025

REFERRAL INDICATION:
Referred by GP for upper GI endoscopy to investigate persistent upper abdominal pain, nausea for 2 months, and ongoing reflux symptoms despite antacid medication.

HISTORY OF PRESENTING COMPLAINT:
Patient reports long-standing irritable bowel syndrome which has progressively worsened. Previously treated with omeprazole for hiatus hernia and reflux symptoms. Patient stopped all medications as felt they were making symptoms worse. Reflux symptoms have improved significantly since stopping medication and taking apple cider vinegar. Currently denies persistent nausea or significant reflux symptoms.

Main complaint is chronic urinary retention with associated abdominal discomfort and flatulence. Patient describes need to urinate frequently but experiences difficulty passing urine, requiring 10 minutes of sitting before gas passes and urination occurs. This happens 6-9 times daily. Reports soft, loose stools occurring twice daily when attempting to urinate.

PAST MEDICAL HISTORY:
- Irritable bowel syndrome (long-standing, progressive)
- Hiatus hernia
- Prostate cancer (PSA 7.8)
- Chronic urinary retention (April 2025)
- Previous colonoscopy with polyp removal

MEDICATIONS:
Currently not taking any regular medications (patient stopped all due to perceived worsening of symptoms).
Previously on omeprazole for reflux.

EXAMINATION:
Rectal examination: No abnormal findings detected.

ASSESSMENT:
Patient's presenting symptoms of abdominal fullness and flatulence are most likely related to chronic urinary retention secondary to prostate enlargement rather than upper GI pathology. Reflux symptoms have significantly improved since stopping medication. Given absence of current upper GI symptoms (nausea, reflux), upper GI endoscopy is not indicated at this time.

PLAN:
1. Refer back to urology for review of chronic urinary retention and discussion of management options
2. Upper GI endoscopy declined by patient as symptoms not currently present
3. Conservative management of reflux symptoms to continue

The patient was counselled regarding the urological nature of his symptoms and declined upper GI endoscopy given the absence of current upper GI symptoms.

Field Clipboard (for EPR paste)

Builds copy buttons from the headings currently in the note, and also lets you copy the entire note.

Summary:

Investigations:

Endoscopy report Tue 16 December 2025 14:46

Field Clipboard (for EPR paste)

Tasks

Feedback