Pediatric Gastroenterology Inpatient Consult Note

Date/Time of Service: [Date and time]

Patient Name: [Full name]

DOB: [MM/DD/YYYY] ([Age])

MRN: [Medical Record Number]

Location: [Inpatient unit/room]

Consulting Service: Pediatric Gastroenterology

Consultant: [Consulting clinician name, credentials]

Consult Overview

Reason for Consult: [Requesting clinician/team and explicit consult question; urgency/timing expectations; clinical context one-liner with age, key condition(s), reason for hospitalization, and immediate concern] (If the consult question required clarification, document that clarification occurred and with whom.)

Recommendations Summary:

1. [Actionable recommendation] (Place time-critical items first. Specify action, timeframe, responsible party when relevant, and brief rationale.)
2. [Actionable recommendation]
3. [Actionable recommendation] (Include only as needed; detailed reasoning belongs in the Plan.)

Communication Log: [Date/time] – Discussed with [name, role] via [in person / phone / secure message]; [read-back confirmation obtained: yes/no] (Omit if chart review only with no recommendations requiring direct communication.)

Data Sources

[Historian(s): patient, parent/guardian, foster caregiver, outside records] [Interpreter use: language, interpreter ID if applicable] (Note reliability concerns if applicable; keep concise if straightforward.)

History of Present Illness

[Opening statement with consult question/chief complaint and brief timeline orienting to why GI is consulted]

[GI-focused symptom characterization including onset, trajectory, severity; stool frequency/consistency/blood description; emesis frequency and character; feeding tolerance and oral intake; hydration indicators; associated symptoms such as fever, weight change, nocturnal symptoms, rash, joint pain, perianal symptoms]

[Current and prior evaluation/therapies this admission; relevant prior GI history] (If information is missing, note what is missing and steps to obtain it.)

Relevant Background

(Include subsections as applicable to the consult. Omit subsections that do not apply.)

Growth and Nutrition

• [Current weight with date; recent weight change/trend; baseline growth pattern if known]
• [Current diet/feeding regimen: formula type/concentration, PO diet, tube feeds, TPN/PPN]
• [Feeding access: NG, G-tube, GJ, J-tube; tube-related issues] (Include only if applicable.)

Past GI/Hepatology History

• [Known diagnoses: IBD, celiac disease, eosinophilic esophagitis, chronic constipation, short bowel/intestinal failure, chronic liver disease, pancreatitis, motility disorders]
• [Prior complications: strictures, fistulae, varices, cholangitis]

Surgical and Procedural History

• [Relevant abdominal surgeries, ostomies, anastomoses, transplant history]
• [Prior endoscopies: dates, key findings, interventions]
• [Feeding tube and central line history] (Especially for intestinal failure patients.)

Medications

• [Current GI-relevant medications: PPIs, laxatives, antiemetics, steroids, biologics, ursodiol, pancreatic enzymes]
• [Hepatotoxic exposures, NSAID use, anticoagulation status]
• [Recent antibiotics, travel, sick contacts, dietary/animal exposures] (For diarrheal illness.)

Allergies

[Drug allergies with reaction types; food allergies if relevant to the presentation]

Family History

[Relevant conditions: IBD, celiac disease, pancreatitis, liver disease, polyposis syndromes, early-onset GI malignancy]

Review of Systems

(Optional. Include only if materially affecting the GI differential or management; otherwise omit entirely.)

[Pertinent positives and negatives by system: skin, musculoskeletal, neurologic, other relevant systems]

Objective

Vitals and Clinical Status

• [Current vitals with interpretation when abnormal]
• [Weight] ([measured / estimated])
• [Relevant I/Os: stool/ostomy output, emesis, NG output, urine output]
• [Current diet order/feeding regimen]

Physical Examination

• General: [Appearance and hydration status]
• Abdomen: [Distension, tenderness location/quality, guarding/rebound, organomegaly, ascites, masses, bowel sounds]
• Skin: [Jaundice, rash, bruising, spider angiomata]
• Perianal: [Findings] (Document chaperone per policy; include only if performed.)
• Tubes/Lines/Stomas: [Site condition, output appearance, complications]

(If exam limited or deferred, state reason.)

Diagnostics

(Present interpreted data with trends and clinical relevance. Note pending or unavailable data.)

Labs: [Trends with dates: hemoglobin, electrolytes, renal function, liver panel with bilirubin fractions and synthetic function, lipase, inflammatory markers as relevant] (Flag critical values and document notification.)

Microbiology/Stool Studies: [GI pathogen panel, C. difficile, stool cultures, O&P, blood cultures if relevant]

Imaging: [Study and date] – [Key impression and your interpretation] (Note discordance between imaging and clinical findings if present.)

Endoscopy/Pathology: [Date, indication, extent, key findings, interventions; biopsy status with salient findings] (For planned procedures: NPO status, coagulation parameters, anesthesia needs.)

Assessment

[Synthesis statement summarizing the clinical picture and GI concerns] (1–3 sentences.)

Problem 1: [Working diagnosis or leading differential]

• [Key supporting and refuting features]
• [Focused differential diagnosis] (Use clinical reasoning language; do not state uncertain diagnoses as established fact.)
• [Red flags if present: hemodynamic instability, ongoing bleeding, obstruction concern, severe malnutrition, cholangitis]

Problem 2: [Working diagnosis or leading differential]

(Add problems as needed, ordered by severity/urgency.)

Plan

Problem 1: [Problem name]

• Diagnostics: [Tests with timing; how results will change management]
• Therapeutics: [Medications with dose, route, frequency; non-pharmacologic interventions; nutrition recommendations]
• Monitoring: [What to trend, interval, escalation thresholds]
• Procedural Planning: [Indication, timing, preparation, anesthesia coordination] (Include only if applicable.)

Problem 2: [Problem name]

• Diagnostics: [As above]
• Therapeutics: [As above]
• Monitoring: [As above]

(Include only applicable domains for each problem.)

Disposition and Follow-up: [GI follow-up plan: daily / intermittent / sign-off; sign-off criteria; outpatient follow-up timing and post-discharge needs]

Co-management Statement: [Advisory only (primary team places orders) / Co-managing defined domain] (If GI placed orders, document and note discussion with primary team.)

Family Communication

(Optional. Include if direct family discussion occurred.)

[Who was present, topics discussed, consent considerations, need for additional support] (Omit section if no family communication occurred.)

Signature

[Electronic signature], [Credentials]

[Contact information]