Irritable Bowel Syndrome
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IRRITABLE BOWEL SYNDROME 1.
CHIEF COMPLAINT •Irritable bowel syndrome
2.
HPI a. Concern: b. Onset•Sudden •Gradual c. Duration: ____ •Recent •A few days •Many days •A few weeks •Many weeks •A few months •Many months •A few years •Many years •Recurrent •N/A. d. Severity: •Mild •Moderate •Severe •Absent •Normal •Increased •Decreased •Stable •No significant change from prior visit. •Details e. Location: Lower abdomen
f. Radiation: g. Quality : •Improving •No change •Worsening •Burning pain •Constricting •Crushing •Dull pain •Heavy •Sharp pain •Squeezing •Stabbing h. Frequancy i. Status j. Context k. Aggravated by : Meals l.
Relieved by : Defecation
m. Associated Symptoms •Clear or white mucorrhea •Dyspepsia •Heartburn •Nausea •Vomiting •Dyspareunia •poor libido •urinary frequency •urinary urgency •Anorexia or weight loss •Fever •Rectal bleeding •Steatorrhea •Lactose and/or fructose intolerance •Gluten intolerance n. Pertinent Negatives
o. Notes 3.
ROS
4.
SYMPTOMS o Constipation o painful defecation o infrequent defecation o Diarrhea o Postprandial urgency o Abdominal pain o Abdominal distention o Clear or white mucorrhea o Dyspepsia o Heartburn o Nausea o Vomiting o Dyspareunia o poor libido o urinary frequency o urinary urgency o Anorexia or weight loss o Fever o Rectal bleeding o Steatorrhea o Lactose and/or fructose intolerance o Gluten intolerance
5.
HISTORY
a. FAMILY HISTORY •Diabetes •Hypertension b. SOCIAL HISTORY •Smoking c. PAST MEDICAL HISTORY •Hypertension •Diabetes
d. SURGICAL HISTORY e. CHRONIC CONDITIONS 6. 7. • •
8. 9.
ALLERGIES PHYSICAL EXAMINATION The patient was tense or anxious. The patient was present with sigmoid tenderness or a palpable sigmoid cord.
SPECIFIC DATA LIKE GRADING TESTS TO BE ORDERED •CBC •Comprehensive metabolic panel •Hemoccult test •Stool examinations: •Breath testing •Thyroid function tests •Serum calcium •Erythrocyte sedimentation rate •C-reactive protein •Small bowel biopsy •H2 breath test •Upper GI barium study •Double-contrast barium enema •Gallbladder ultrasonography •Abdominal CT scan •Anal manometry •Endoscopy •Esophagogastroduodenoscopy •Colonoscopy
10. ASSESSMENT/PLAN •Psychiatric counseling for patients with anxiety •Cognitive behavioral therapy
11. EDUCATION •Fiber supplementation may improve symptoms of constipation and diarrhea. •Take Polycarbophil compounds •Take judicious water Avoid caffeine Avoid legume •Avoid or limit lactose and/or fructose •Take supplement calcium 12. MEDICATION •Dicyclomine hydrochloride •Hyoscyamine sulfate •Diphenoxylate hydrochloride •Loperamide •Imipramine •Amitriptyline •Cisapride monohydrate •Tegaserod •Alosetron •Lubiprostone •Methylcellulose •Psyllium 13. FOLLOW UP
CHIEF COMPLAINT •Irritable bowel syndrome
2.
HPI a. Concern: b. Onset•Sudden •Gradual c. Duration: ____ •Recent •A few days •Many days •A few weeks •Many weeks •A few months •Many months •A few years •Many years •Recurrent •N/A. d. Severity: •Mild •Moderate •Severe •Absent •Normal •Increased •Decreased •Stable •No significant change from prior visit. •Details e. Location: Lower abdomen
f. Radiation: g. Quality : •Improving •No change •Worsening •Burning pain •Constricting •Crushing •Dull pain •Heavy •Sharp pain •Squeezing •Stabbing h. Frequancy i. Status j. Context k. Aggravated by : Meals l.
Relieved by : Defecation
m. Associated Symptoms •Clear or white mucorrhea •Dyspepsia •Heartburn •Nausea •Vomiting •Dyspareunia •poor libido •urinary frequency •urinary urgency •Anorexia or weight loss •Fever •Rectal bleeding •Steatorrhea •Lactose and/or fructose intolerance •Gluten intolerance n. Pertinent Negatives
o. Notes 3.
ROS
4.
SYMPTOMS o Constipation o painful defecation o infrequent defecation o Diarrhea o Postprandial urgency o Abdominal pain o Abdominal distention o Clear or white mucorrhea o Dyspepsia o Heartburn o Nausea o Vomiting o Dyspareunia o poor libido o urinary frequency o urinary urgency o Anorexia or weight loss o Fever o Rectal bleeding o Steatorrhea o Lactose and/or fructose intolerance o Gluten intolerance
5.
HISTORY
a. FAMILY HISTORY •Diabetes •Hypertension b. SOCIAL HISTORY •Smoking c. PAST MEDICAL HISTORY •Hypertension •Diabetes
d. SURGICAL HISTORY e. CHRONIC CONDITIONS 6. 7. • •
8. 9.
ALLERGIES PHYSICAL EXAMINATION The patient was tense or anxious. The patient was present with sigmoid tenderness or a palpable sigmoid cord.
SPECIFIC DATA LIKE GRADING TESTS TO BE ORDERED •CBC •Comprehensive metabolic panel •Hemoccult test •Stool examinations: •Breath testing •Thyroid function tests •Serum calcium •Erythrocyte sedimentation rate •C-reactive protein •Small bowel biopsy •H2 breath test •Upper GI barium study •Double-contrast barium enema •Gallbladder ultrasonography •Abdominal CT scan •Anal manometry •Endoscopy •Esophagogastroduodenoscopy •Colonoscopy
10. ASSESSMENT/PLAN •Psychiatric counseling for patients with anxiety •Cognitive behavioral therapy
11. EDUCATION •Fiber supplementation may improve symptoms of constipation and diarrhea. •Take Polycarbophil compounds •Take judicious water Avoid caffeine Avoid legume •Avoid or limit lactose and/or fructose •Take supplement calcium 12. MEDICATION •Dicyclomine hydrochloride •Hyoscyamine sulfate •Diphenoxylate hydrochloride •Loperamide •Imipramine •Amitriptyline •Cisapride monohydrate •Tegaserod •Alosetron •Lubiprostone •Methylcellulose •Psyllium 13. FOLLOW UP
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