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Letter (111 days ago 14:48)

Letter Tue 16 December 2025 14:48

Last Modified: 111 days ago

MRN:

Content:

GASTROENTEROLOGY CONSULTATION NOTE

Patient: Victor Morgan
MRN: 322915
Date: 16/12/2025
Consultant: Dr Rob Yap

REFERRAL REASON:
Referred by GP for upper GI endoscopy to investigate persistent upper abdominal pain, nausea, and reflux symptoms.

HISTORY OF PRESENTING COMPLAINT:
Mr Morgan reports long-standing IBS symptoms which have progressively worsened. Main complaints include:
- Chronic urinary retention with associated abdominal bloating and flatulence
- Difficulty with micturition - requires 10 minutes to pass urine with associated gas pressure
- Bowel movements 6-9 times daily, described as loose/squishy consistency with lighter colour
- Previous reflux symptoms related to hiatus hernia, now much improved since stopping all medications
- Episodes of morning nausea and syncope whilst on PPI therapy (now discontinued)

PAST MEDICAL HISTORY:
- Hiatus hernia
- Prostate cancer (PSA 7.8) - declined active treatment
- Chronic urinary retention (April 2025) - declined catheterisation
- Previous colonoscopies with polyp removal
- IBS (onset following third colonoscopy)

MEDICATIONS:
Currently taking no regular medications. Previously on omeprazole (discontinued due to worsening symptoms).

EXAMINATION:
Rectal examination: No abnormal findings
General examination: Unremarkable

ASSESSMENT:
Patient's upper GI symptoms have largely resolved since discontinuing PPI therapy. Current symptoms of abdominal bloating and flatulence are consistent with chronic urinary retention secondary to enlarged prostate rather than upper GI pathology. Given absence of current upper GI symptoms, endoscopy not clinically indicated.

PLAN:
1. Upper GI endoscopy declined by patient - appropriate given symptom resolution
2. Referral letter to urology for review of chronic urinary retention and management options
3. Patient to continue current symptom management approach

Dr Rob Yap
Consultant Gastroenterologist

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Endoscopy report (111 days ago 14:46)

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.

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