Date:
Patient:
MRN:
Clinician: (Gastroenterologist, Colorectal Surgeon, Urogynecologist)
Reason for Visit:
Follow-up for fecal incontinence
Evaluation of FI severity and impact on quality of life
Treatment plan discussion or adjustment
Consideration for additional testing
History of Present Illness:
Onset, duration, and frequency of fecal incontinence episodes
Type of incontinence (urging, passive leakage)
Stool consistency (diarrhea, constipation)
Presence of associated symptoms (urgency, bloating, rectal pain)
Impact of FI on daily activities and social life
Past Medical History:
Underlying medical conditions that may contribute to FI (neurological disorders, childbirth, prior anorectal surgery)
History of bowel dysfunction (diarrhea, constipation)
Surgical History:
Previous abdominal or pelvic surgeries, including childbirth deliveries
Medications:
Current medications that may affect bowel function (laxatives, antidiarrheals)
Social History:
Dietary habits (fiber intake, fluid intake)
Physical activity level
Family History:
Family history of FI or bowel disorders
Physical Exam:
General: Nutritional status, signs of dehydration
Abdominal: Distention, tenderness
Rectal: Digital rectal exam to assess sphincter tone and rectal contents
Incontinence Assessment Tools:
Consider using validated tools to assess FI severity and impact on quality of life (e.g., Cleveland Clinic Incontinence Score, Wexner Score)
Labs:
Consider mentioning specific labs ordered based on clinical suspicion:
Thyroid function tests (hypothyroidism can contribute to constipation)
Electrolytes – to assess for dehydration
Imaging:
Imaging studies are not routinely performed for FI diagnosis but may be used to rule out other conditions:
Defecography (X-ray of rectum during defecation)
Pelvic MRI – to assess pelvic floor anatomy
Anorectal Manometry:
May be performed to evaluate anal sphincter function and rectal sensation.
Assessment:
Identify the type and severity of fecal incontinence.
Determine the underlying cause(s) of FI based on history, physical exam, and investigations.
Consider potential contributing factors:
Pelvic floor weakness
Sphincter dysfunction
Neurological disorders
Diarrhea or constipation
Plan:
Outline a treatment plan based on the underlying cause and severity of FI:
Dietary modifications: Increase fiber intake and fluid intake to promote regular bowel movements.
Bowel management program: Scheduled toileting, biofeedback training to strengthen pelvic floor muscles.
Medication adjustments: Address constipation or diarrhea with appropriate medications.
Sacral nerve stimulation (SNS): Neuromodulation therapy for refractory FI.
Surgery: May be considered for specific types of FI or anatomical abnormalities.
Prognosis:
Briefly discuss the prognosis. With appropriate treatment, many patients with FI can experience significant improvement in symptoms and quality of life.
Education:
Document any education provided to the patient regarding:
The nature of fecal incontinence and its causes
Importance of dietary and lifestyle modifications
Available treatment options and their potential benefits and risks
Support groups and resources available for FI patients
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the plan and their emotional impact of FI.
Consider mentioning the importance of ongoing communication and potential need to adjust the treatment plan over time.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a healthcare professional for diagnosis and treatment recommendations.