Date:
Patient: [Patient Name], [MRN]
Attending Physician: [Physician Name]
Reason for Visit: Follow-up for chronic diarrhea, evaluation of worsening symptoms, or diagnostic workup.
SOAP
Subjective (S):
History of Present Illness:
Inquire about the following details of the diarrhea:
Duration (more than 4 weeks)
Frequency and urgency
Volume and consistency of stools (watery, loose, bloody)
Presence of abdominal pain, cramping, or bloating
Nausea, vomiting, or fever (may suggest infectious cause)
Changes in bowel habits (constipation alternating with diarrhea)
Dietary triggers (e.g., lactose intolerance, gluten sensitivity)
Past Medical History:
Briefly summarize relevant past medical history, including:
Underlying conditions that might contribute to chronic diarrhea (e.g., inflammatory bowel disease (IBD), irritable bowel syndrome (IBS), celiac disease, lactose intolerance)
Previous surgeries (intestinal resection)
Medications that can cause diarrhea (e.g., antibiotics, laxatives)
Travel history (increased risk of infectious diarrhea)
Social History:
Inquire about dietary habits and any recent changes in diet.
Ask about stress levels, as stress can worsen symptoms in some cases.
Objective (O):
Vital Signs:
Record temperature, heart rate, blood pressure, and respiratory rate.
Physical Exam:
Perform a focused physical exam, including:
Abdominal exam: Assess for tenderness, distention, or masses.
Signs of dehydration (dry mucous membranes, poor skin turgor)
Rectal exam: Evaluate for rectal bleeding or hemorrhoids.
Assessment (A):
Severity of Chronic Diarrhea:
Assess the severity of chronic diarrhea based on frequency, volume of stool loss, and impact on daily life (dehydration, weight loss).
Differential Diagnosis:
Based on the history, physical exam, and any additional testing, consider a differential diagnosis for the chronic diarrhea, including:
Infectious diarrhea (viral, bacterial, parasitic)
Inflammatory bowel disease (IBD) – Crohn’s disease, ulcerative colitis
Irritable bowel syndrome (IBS)
Microscopic colitis
Celiac disease
Lactose intolerance
Malabsorption syndromes
Medication-induced diarrhea
Dehydration Status:
Assess for dehydration based on clinical signs and symptoms (mentioned above) and may require laboratory testing (electrolytes).
Plan (P):
Diagnostic Testing (if indicated):
Order additional tests based on the suspected cause, such as:
Stool tests (culture, ova and parasites, occult blood)
Complete blood count (CBC) and electrolytes to assess for infection or dehydration.
Imaging studies (abdominal X-ray, CT scan) – may be needed in some cases.
Lactose tolerance test
Celiac disease serology and possibly endoscopy with biopsy
Treatment Plan:
Develop a treatment plan based on the identified cause of the diarrhea. Options may include:
Rehydration therapy (oral or intravenous fluids) for dehydration.
Antibiotics (for bacterial infections) or antiparasitic medications.
Antidiarrheal medications (loperamide) – use with caution and for short duration.
Dietary modifications (elimination diet for suspected food intolerances, lactose-free diet for lactose intolerance, gluten-free diet for celiac disease).
Medications to manage underlying conditions (anti-inflammatory drugs for IBD).
Referral to a gastroenterologist for further evaluation and management (if indicated).
Follow-up:
Schedule follow-up visits to assess treatment response, symptom improvement, and adjust the plan as needed. Define the frequency of follow-up based on the severity of symptoms, response to treatment, and suspected cause.
Patient Education:
Educate the patient about the likely cause of their chronic diarrhea and the rationale for the treatment plan.
Provide dietary recommendations based on the diagnosis (e.g., elimination diet, lactose restriction).
Discuss proper hydration and how to recognize signs of dehydration.
Instruct on medication use and potential side effects.
Offer resources for support groups or educational materials on managing chronic diarrhea.