Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for CIPO, evaluation of worsening symptoms, medication management, or nutritional assessment.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the following details of symptoms:
Frequency and severity of abdominal pain (cramping, distention)
Nausea and vomiting
Constipation (may be paradoxical, alternating with diarrhea)
Bloating and early satiety
Weight loss or difficulty maintaining weight
Urinary retention or overflow incontinence (possible complication)
Ask about recent changes in symptoms, dietary intake, or response to previous treatments.
Past Medical History:
Briefly summarize relevant past medical history, including:
Date of CIPO diagnosis
Underlying cause of CIPO (e.g., neurological, muscular, idiopathic)
Previous surgeries (intestinal resections)
History of hospital admissions for CIPO complications
Current medications and their effectiveness
Social History:
Inquire about dietary habits and any recent changes.
Ask about psychosocial stressors and their impact on symptoms.
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Abdominal Exam:
Assess for abdominal distention, tenderness, or masses.
Listen for bowel sounds (may be hypoactive or absent in severe cases).
Laboratory Tests (review recent results):
Electrolytes (may be imbalanced due to dehydration or malnutrition)
Complete blood count (CBC) – may show anemia if malnutrition is present
Consider additional tests as indicated:
Thyroid function tests (hypothyroidism can mimic CIPO symptoms)
Serum protein levels (assess for malnutrition)
Imaging Studies (review recent results):
Abdominal X-ray – may show signs of gas distention
Abdominal CT scan – may provide more detailed information about bowel dilatation and exclude other causes of obstruction
Assessment (A):
Severity of CIPO:
Assess the severity of CIPO based on symptom frequency, impact on daily life, and nutritional status.
Nutritional Status:
Evaluate weight loss, laboratory findings, and dietary intake to assess for malnutrition.
Treatment Response:
Evaluate the response to previous treatments (prokinetics, nutritional support) and identify any side effects.
Plan (P):
Treatment Plan:
Develop a treatment plan based on the severity of CIPO and specific needs of the patient. Options may include:
Nutritional Support:
Enteral nutrition (tube feeding) – often a mainstay of treatment for CIPO patients who cannot meet nutritional requirements orally.
Parenteral nutrition (intravenous feeding) – may be necessary in some cases.
Medications:
Prokinetic agents (e.g., erythromycin) to stimulate intestinal motility.
Anti-emetics for nausea and vomiting.
Pain management medications.
Bowel decompression: Nasogastric tube or surgical decompression may be needed in severe cases or for acute exacerbations.
Surgery: Rarely considered, may be an option for addressing underlying causes (e.g., strictures) or managing complications.
Referral (if indicated):
Consider referral to a gastroenterologist with expertise in CIPO, a registered dietitian for nutritional counseling, or a pain specialist.
Follow-up:
Schedule follow-up visits to monitor symptoms, nutritional status, response to treatment, and adjust the plan as needed.
Define the frequency of follow-up based on disease severity, treatment plan, and presence of complications.
Patient Education:
Educate the patient about CIPO, its causes, and the rationale for the treatment plan.
Provide information on dietary modifications and the importance of nutritional support (if applicable).
Instruct on medication use and potential side effects.
Discuss the importance of managing stress and maintaining a healthy lifestyle.
Offer resources for support groups or educational materials on managing CIPO.