Date:
Patient:
MRN:
Clinician: (Gastroenterologist, Primary Care Physician)
Reason for Visit:
Follow-up for functional dyspepsia
Evaluation of symptom control and response to treatment
Discussion of dietary modifications and lifestyle changes
History of Present Illness:
Briefly describe the patient’s current symptoms:
Frequency and severity of upper abdominal pain or discomfort (burning, gnawing, aching)
Presence of associated symptoms (early satiety – feeling full after eating a small amount, bloating, nausea)
Impact of symptoms on daily activities and quality of life
Past Medical History:
Gastrointestinal conditions (peptic ulcer disease, gastroesophageal reflux disease – GERD) previously ruled out through investigations (endoscopy, upper GI series)
History of medications that can worsen dyspepsia (aspirin, NSAIDs)
Other medical conditions (e.g., anxiety, depression)
Social History:
Diet (high intake of fatty, spicy, or acidic foods)
Stress levels and potential association with symptoms
Smoking and alcohol use (potential risk factors)
Physical Exam:
Vital Signs: (usually normal)
Abdominal: Normal exam unless there is a suspicion of another underlying condition.
Labs (not routinely used for diagnosis, may be ordered to rule out other conditions):
Complete Blood Count (CBC)
Basic Metabolic Panel (BMP)
Celiac serology (if suspicion of gluten sensitivity)
Imaging (not routinely used for diagnosis):
Upper endoscopy or upper GI series (may have been performed previously to rule out peptic ulcer disease or GERD)
Assessment:
Confirm the diagnosis of functional dyspepsia based on characteristic symptoms and absence of structural abnormalities on investigations.
Evaluate symptom severity and impact on daily life.
Identify potential contributing factors (diet, stress, medications).
Plan:
Outline the treatment plan focused on symptom management and lifestyle modifications:
Dietary modifications: Recommend a bland diet, smaller and more frequent meals, and avoiding trigger foods (fatty, spicy, acidic).
Lifestyle changes: Stress management techniques (relaxation techniques, exercise), smoking cessation, and limiting alcohol intake.
Medications: Consider medications like proton pump inhibitors (PPIs) for a short trial period to see if they improve symptoms. Antidepressants may be helpful if there is a strong association with stress or anxiety.
Education:
Document any education provided to the patient regarding:
The nature of functional dyspepsia and the absence of structural abnormalities in the digestive system.
The importance of dietary modifications and keeping a food diary to identify trigger foods.
Stress management techniques and healthy lifestyle habits to promote gut health.
The potential benefits and limitations of medications used for symptom control.
Prognosis:
Briefly discuss the prognosis. Functional dyspepsia is a chronic condition, but symptoms can be effectively managed with lifestyle modifications and medications.
Emphasize the importance of ongoing communication with the healthcare provider to adjust the treatment plan as needed.
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about symptom management.
Consider the potential need for referral to a specialist (gastroenterologist) if symptoms are severe or do not respond to initial treatment approaches.
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, treatment recommendations, and management of functional dyspepsia.