Subjective
Date of visit
Reason for visit (initial presentation, follow-up for PJS, GI symptoms)
History of present illness:
Gastrointestinal (GI) symptoms (if present):
Abdominal pain
Nausea and vomiting
Diarrhea or constipation
Bleeding (rectal bleeding)
Skin findings:
Presence, location, and number of mucocutaneous pigmented macules (around lips, mouth, eyes, genitalia)
Any changes in the appearance of the macules
Family history (presence of PJS in first-degree relatives)
Past medical history (relevant surgeries for polyps or GI issues)
Medications (current medications)
Allergies
Objective
Vital signs (temperature, heart rate, blood pressure)
Physical exam:
General (signs of malnutrition, anemia)
Skin examination:
Confirmation of mucocutaneous pigmented macules (size, color, distribution)
Examination for other skin findings suggestive of PJS (e.g., freckles on palms and soles)
Abdominal examination (tenderness, masses)
Assessment
Peutz-Jeghers syndrome (known diagnosis or suspected based on clinical presentation)
Consideration of GI symptoms in the context of PJS (may be unrelated or PJS-related)
Risk of developing GI cancers (increased risk for intestinal adenocarcinoma)
Plan
Management of GI symptoms:
Depending on the symptoms, consider medications (antidiarrheals, antiemetics) or dietary modifications.
Surveillance for GI cancers:
Regular colonoscopy and upper endoscopy (schedule based on age and risk factors)
Imaging studies (may be indicated based on symptoms):
Abdominal CT scan
Capsule endoscopy (for small bowel evaluation)
Genetic counseling (if not already completed) to discuss implications for family members
Education
Explain the diagnosis and management plan for PJS
Importance of adherence to surveillance recommendations
Diet and lifestyle modifications to promote gut health (if applicable)
Follow-up
Schedule for next appointment:
Monitor GI symptoms and response to treatment
Schedule follow-up colonoscopy and/or endoscopy
Address any new concerns
Note: This template is a guide and may need to be modified based on the individual patient’s presentation, severity of PJS, and presence of GI symptoms.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and management of Peutz-Jeghers syndrome.