Irritable Bowel Syndrome follow-up

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Returns for an ‍irritable bowel syndrome follow-up

Last visit was ‍ ‍months ago

Progress since last visit: ‍unchangedimproveddeterioratedvariableresolved



Current symptoms:

‍abdominal pain, ‍diffuse, ‍dull, ‍mild

‍bloating

‍excessive gas

‍diarrhea, ‍ episodes ‍per day, ‍

‍constipation

‍feeling of incomplete emptying

‍hematochezia, ‍bright reddark red, ‍around stoolsmixed with stools, ‍withwithout clots

‍mucus in the stool

‍fatigue

‍unexplained weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths

‍loss of appetite

‍nausea

‍vomiting, ‍ episodes ‍per day, ‍, ‍hematemesis

‍anxiety



Food triggers identified: ‍nonedairygluten

Dietary changes: ‍nonelow FODMAP, ‍effectiveineffective

Stress management: ‍nonemeditation, ‍effectiveineffective



Medications: ‍antispasmodics, ‍bulking agents, ‍laxatives, ‍antidiarrheals, ‍probiotics



Labs: ‍unremarkable

Hb: ‍ ‍normal

Leukocytes: ‍ ‍normal

CRP: ‍ ‍normal

Creatinine: ‍ ‍normal

TSH: ‍ ‍normal

Anti-transglutaminase: ‍ ‍normal

Stool culture: ‍ ‍negative

Parasites: ‍ ‍negative

C. difficile: ‍ ‍negative

FIT test: ‍positivenegative

Calprotectin: ‍positivenegative





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Metrics: weight: ‍ ‍kglbs, height: ‍ cm, waist: ‍ cm, BMI: ‍

Eyes: conjunctiva/sclera ‍normal, lids/lashes ‍normal, cornea ‍intact, ‍PERRL, extraocular movements ‍intact, OD 20/‍, OS 20/‍

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍

Neurologic: cranial nerves ‍intact, strength ‍intact 5/5, sensation ‍intact, reflexes ‍intact 2+, cerebellar function ‍intact, gait ‍steady





ASSESSMENT:

‍Irritable Bowel Syndrome, ‍well controlled

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, chronic functional constipation, chronic functional diarrhea, GERD, peptic ulcer disease, gallbladder disease, pancreatic insufficiency





PLAN:

Investigations:

- Blood work: ‍CBC, ‍CRP, ‍TSH, ‍ferritin, ‍vitamin B12, ‍albumin, ‍glucose, ‍LFTs, ‍lipase, ‍anti-tranglutaminase

- Stools: ‍bacterial culture, ‍parasitic culture, ‍C. difficile toxin, ‍FIT test, ‍calprotectin

- Colonoscopy

- Abdominal ultrasound

Treatments:

- Psychoeducation about irritable bowel syndrome

- Dietary modifications: ‍FODMAP diet, ‍increase fiber intake, ‍avoid trigger foods

- Regular exercise

- Stress management techniques

- Sleep hygiene

- ‍IBS medications

Further care:

- Referral to dietitian

- Referral to gastroenterologist

- Referral to psychologist

- Follow-up in ‍ ‍weeksmonths

- Return if symptoms worsen or if new symptoms develop such as weight loss, blood in stools, or fever