Gastroenterology Consultation Note (Inpatient)

Date/Time: [Consult date and time]
Consulting Service: GI Consultation – Inpatient
Patient: [Patient name and identifiers]
Location: [Unit/room]
Admitting Service: [Primary team]
Admission Date: [Admission date]
Requesting Clinician/Service: [Name/service]
Reason for Consult: [Specific clinical question]
Sources of History: [Patient / family / nursing / chart review / outside records] (Note limitations; if patient unable to provide history, state reason and list collateral sources)

At-a-Glance Recommendations

• [Resuscitation and monitoring orders] (NPO status, IV access, hemodynamic targets, transfusion thresholds)
• [Key diagnostics to obtain now with timing]
• [Medication actions] (Start/stop/hold; explicitly address antithrombotics with agent and last dose)
• [Procedure recommendation with timing/urgency level if indicated]
• [Escalation triggers and when to page GI]

History of Present Illness

[Consult framing] (1–3 sentences: presenting GI problem, severity/trajectory, why GI is involved now)

[Chronological HPI] (Onset, duration, progression, triggers/relievers, associated symptoms. For bleeding: hematemesis/coffee-ground/melena/hematochezia, syncope, last normal stool. For liver/biliary: jaundice, RUQ pain, fevers, confusion, ascites. For pancreas: epigastric pain radiation, N/V, fevers, gallstone history. For obstruction: distension, vomiting, obstipation, surgical history. For IBD: stool frequency, blood, urgency, extraintestinal symptoms. Include prior endoscopic/surgical GI history and recent exposures: NSAIDs, alcohol, hepatotoxins, supplements, new medications, antibiotics, travel.)

Pertinent Medical History

• Relevant GI history: [Ulcers / varices / cirrhosis / pancreatitis / IBD / malignancy / prior GI bleeds / strictures / stents / prior ERCP] (Include dates and key outcomes)
• Relevant non-GI comorbidities: [Cardiovascular disease / CKD / transplant / immunosuppression / coagulopathy] (Include only if affecting current risk or management)
• Current Medications (targeted list):
  • Anticoagulants/antiplatelets: [Agent, dose, indication, last dose date/time] (If unknown: "Unknown—patient unable to recall; MAR reviewed, no administration documented since [time]")
  • NSAIDs/aspirin: [Agent; primary vs secondary prevention; last dose]
  • Steroids/biologics/immunosuppressants: [Agent, dose, schedule]
  • Acid suppression/vasoactives already started: [Agent, dose, start time]
• Allergies: [Medication / contrast / latex with reaction type]
• Social history: [Alcohol quantity/timeline; substance use; high-risk exposures] (Omit if not relevant to consult)
• Family history: [IBD / colorectal cancer / liver disease] (Omit if not relevant to consult)

Physical Examination

• General: [Appearance, distress level, mental status]
• Vitals: [Current vitals with hemodynamic trend; fever; oxygenation]
• Abdomen: [Distension; bowel sounds; tenderness location and severity; peritoneal signs; masses; hepatosplenomegaly]
• Skin: [Jaundice; pallor; stigmata of chronic liver disease] (Include if relevant)
• Volume status: [Edema; ascites signs]
• Neuro: [Encephalopathy findings; asterixis; orientation] (Include if liver failure suspected)
• Rectal exam: [Gross blood / melena / guaiac status / tone] (If not performed and clinically relevant, state why)

Data Review

• Vitals/Hemodynamics: [Current vitals; trend summary; I/Os if relevant]
• Labs: [Key values with timestamps and trends] (For bleeding: CBC trend, coags, lactate, BUN/Cr. For liver: AST/ALT, ALP, bilirubin fractions, INR, albumin. For pancreas: lipase, BUN, calcium, triglycerides. For infection: WBC, lactate, culture status.)
• Imaging: [Relevant US/CT/MRCP/CTA findings and impression; note limitations or need for additional imaging]
• Prior GI Procedures: [Summary of relevant endoscopy/ERCP findings and pathology with dates] (Include if relevant to current consult)

Assessment

[One-sentence GI impression: synthesis of presentation, key findings, severity, and leading diagnosis]

• Problem 1: [Problem name] – [Most likely diagnosis] (Differentials: [differential A / differential B])
• Problem 2: [Problem name] – [Most likely diagnosis] (Include only if applicable)

Plan

Problem 1 – [Name]

• Assessment: [1–2 sentences: what is happening and why]
• Diagnostics: [Tests to obtain with timing and urgency]
• Therapeutics: [Medications, fluids, transfusion targets, nutrition]
• Procedure recommendation: [Indication; timing: emergent / urgent / within 24h / non-urgent; prerequisites; contingency if not feasible]
  • Medical necessity: [Rationale for procedure]
  • Risk assessment: [Hemodynamic status; airway concerns; bleeding risk; antithrombotic status with last dose]
  • Preparation: [NPO timing; IV access; blood bank orders; bowel prep if colonoscopy; antibiotics if indicated]
  • Sedation/anesthesia: [Sedation plan; ICU vs endoscopy suite; aspiration risk] (Include if relevant)
  • Consent: [Obtained by (name/role) / Deferred (reason, timeline) / Patient lacks capacity (surrogate plan) / Declined (risks and alternatives discussed)]
• Monitoring: [Parameters and frequency]
• Escalation: [Specific triggers to page GI or escalate care]
• Responsibilities: GI will manage: [tasks]. Primary team to manage: [tasks].

Problem 2 – [Name]

(Include only if applicable; follow same structure as Problem 1)

Condition-Specific Elements

(Include relevant elements based on consult type)

• GI bleeding: [Risk stratification; transfusion threshold; antithrombotic holding/reversal plan with restart timing; airway precautions if hematemesis or AMS]
• Cholangitis: [Severity grade; drainage timing and modality; antibiotic selection]
• Pancreatitis: [Etiology workup; fluid strategy; early feeding plan; ERCP indications if biliary; antibiotics only if infected necrosis]
• IBD flare: [Infection exclusion (C. difficile); endoscopy timing; rescue therapy triggers; surgical consult criteria]
• Obstruction: [Decompression plan; endoscopic vs surgical approach; goals: bridge / palliation / definitive]

Communication

• Discussed with: [Primary team / patient / family] (Include names/roles)
• Shared decisions: [Key decisions, patient preferences, goals of care if relevant]
• Contingency instructions: [When to escalate; who to contact]
• GI follow-up: [Daily follow / sign-off; criteria for re-consultation]