Recommendation to refer the patient to a gastroenterologist for an examination of the upper digestive tract (esophagus, stomach, and duodenum) using an endoscope, along with additional assessment as deemed necessary by the specialist.
Used when the primary care physician or other specialist suspects a condition requiring specialized expertise in the digestive system, such as persistent heartburn, difficulty swallowing, abdominal pain, or unexplained weight loss. An upper endoscopy allows for visualization and potential tissue sampling of the upper gastrointestinal tract.
"Patient presenting with persistent epigastric pain. Consult gastroenterology for upper endoscopy and further evaluation."
This phrase is typically used in the plan section of a medical note, indicating the next steps in patient care.
Common questions about using medical phrases in clinical documentation