Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
主诉 (zhǔ訴) Chief Complaint:
Document the patient’s main concerns related to interstitial cystitis/bladder pain syndrome (IC/BPS). This may include:
Pelvic pain, often described as pressure, burning, or urgency localized to the lower abdomen or bladder area.
Urinary frequency and urgency (not necessarily increased urine output).
Pain during bladder filling that may improve with urination (characteristic symptom).
Nocturia (waking up at night to urinate).
Dyspareunia (painful intercourse).
现病史 (xiàn bìng shǐ) History of Present Illness:
Onset and duration of symptoms.
Severity and character of pain (constant, intermittent, flares).
Frequency and urgency of urination.
Nocturia frequency.
Impact on daily life (work, sleep, sexual activity).
Prior urinary tract infections (UTIs) – may trigger or worsen IC/BPS.
既往史 (jì wàng shǐ) Past Medical History:
Prior pelvic surgeries or procedures (may increase risk).
Underlying medical conditions (e.g., pelvic floor dysfunction, endometriosis).
Mental health history (stress, anxiety, depression – can worsen symptoms).
家族史 (jiā zú shǐ) Family History:
Family history of IC/BPS (uncommon).
社会史 (shè huì shǐ) Social History:
Stressful life events (may exacerbate symptoms).
Dietary habits (certain foods or drinks may trigger symptoms – caffeine, alcohol, spicy foods).
查体 (chá tǐ) Physical Examination:
Pelvic examination:
Assess for tenderness in the bladder area.
Rule out other pelvic conditions.
Urinalysis and urine culture:
To rule out UTI or other urinary tract pathology.
辅助检查 (fú zhu zhuān chá) Laboratory Tests:
Cystoscopy with hydrodistension (gold standard for diagnosis, but invasive):
Visualizes bladder lining for abnormalities (e.g., Hunner’s lesions).
Bladder is distended with fluid to assess for pain and capacity.
Potassium sensitivity test (performed during cystoscopy):
Measures bladder wall response to potassium chloride solution (may suggest IC/BPS).
影像学检查 (yǐng xiàng xué jiǎn chá) Imaging Studies:
Imaging studies like pelvic ultrasound or cystogram (X-ray with bladder contrast) are usually not needed for diagnosis but may be used to rule out other conditions.
诊断 (zhěn duàn) Diagnosis:
Interstitial cystitis/Bladder pain syndrome (IC/BPS).
分期 (fēn qī) Staging (optional):
There is no formal staging system for IC/BPS. Some classifications categorize based on symptom severity.
治疗方案 (zhì liáo fāng àn) Treatment Plan:
Treatment for IC/BPS focuses on symptom management and may include:
Lifestyle modifications: stress management, dietary adjustments, pelvic floor muscle therapy.
Bladder distention techniques: performed in a clinic setting to stretch the bladder wall and reduce pain.
Oral medications: pentosan polysulfate (Elmiron), antidepressants (amitriptyline), bladder pain relievers (pyridium).
Intravesical therapies: medications or substances instilled directly into the bladder (e.g., hyaluronic acid, lidocaine).
Neuromodulation techniques: electrical stimulation to modulate bladder nerves (less common).
预后 (yù hòu) Prognosis:
IC/BPS is a chronic condition, but symptoms can be effectively managed with treatment.
Discuss the importance of ongoing management and potential for symptom flares.
健康指导 (jiàn kāng zhǐ dào) Patient Education:
Importance of following treatment recommendations and lifestyle modifications.
Stress management techniques.
Identifying and avoiding personal triggers.
Pelvic floor muscle exercises (Kegels) for some patients.
Support groups and resources for IC/BPS patients.
Signs and symptoms to watch for that may necessitate a return visit (e.g., worsening pain, blood in urine, fever).