IBS
Age: years old
Gender:
HISTORY:
Presents with a - history of
Symptoms include:
, , ,
, episodes ,
, , , clots
, over
, episodes , ,
Worsening factors:
Alleviating factors: ,
Contributing factors:
no history of: ,
no family history of:
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Abdomen: , , , , bowel sounds , ,
Anorectal: DRE , prostate , , , anus
Pelvic: external genitalia , vagina , cervix , uterus , adnexa ,
Genital: penis , testes and epididymis ,
ASSESSMENT:
DDx: irritable bowel disease, functional GI symptoms, lactose intolerance, celiac disease, food intolerances, psychological stressors, inflammatory bowel disease, gastroenteritis, small intestinal bacterial overgrowth, thyroid dysfunction, colorectal cancer, endometriosis, chronic functional constipation, chronic functional diarrhea, GERD, peptic ulcer disease, gallbladder disease, pancreatic insufficiency
PLAN:
Investigations:
- Blood work: , , , , , , , , ,
- Stools: , , ,
- Colonoscopy
- Abdominal ultrasound
Treatments:
- Psychoeducation about irritable bowel syndrome
- Dietary modifications: , ,
- Regular exercise
- Stress management techniques
- Sleep hygiene
-
Further care:
- Referral to dietitian
- Referral to psychologist
- Referral to gastroenterologist
- Follow-up in
- Return if symptoms worsen or if new symptoms develop such as weight loss, blood in stools, or fever
HISTORY: EXAM: ASSESSMENT: PLAN: