Consultation Notes Dr. Specialist - September 8, 2016 Dear Dr. Henry Leven: Thank you for referring Ms. Everywoman for evaluation. As you know, she is a 40-year-old woman who has had chronic gastrointestinal symptoms. Approximately 18 years ago, she was hospitalized with a bleeding ulcer. She had a CT scan of the abdomen, which revealed findings consistent with focal nodular hyperplasia (FNH). She has had epigastric abdominal pain as well as a significant change in her bowel movements from baseline constipation to frequent diarrhea. The past medical history is otherwise negative. She takes no prescription medications. The remainder of the history is not contributory. Physical examination revealed a well-appearing woman. The vital signs were normal. The head and neck were unremarkable. The lung fields were clear. The heart exam was normal. The abdomen was obese with normal bowel sounds. There was no tenderness, mass, or hepatosplenomegaly. Endoscopic evaluation revealed a normal colonoscopy. Biopsies taken throughout the colon were essentially unremarkable. Stool tests for pathogenic organisms were negative. Of note, on the upper endoscopy examination, no significant abnormalities were seen; however, upon biopsy, features of celiac disease were noted. In summary, this 40-year-old woman has evidence of celiac disease. We discussed the diagnosis in detail in the office. She was advised to undertake a lifelong gluten-free diet. Followup laboratories in my office were notable for a low serum iron with a low-normal ferritin. The bone density was normal. Repeat triple-phase CT scan of the liver revealed no change in the right hepatic lobe lesion, which is consistent with FNH. I advised periodic reevaluation of the liver with imaging, as well as followup for any potential development of nutritional deficiencies. She should take an iron supplement and continue on a lifelong gluten-free diet. Thank you for the courtesy of this referral. I would be pleased to see Ms. Everywoman in followup.