Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Encounter]
Subjective:
Symptoms:
Duration and severity of IBS symptoms (abdominal pain, cramping, bloating, diarrhea, constipation, urgency)
Character and frequency of bowel movements (diarrhea, constipation, or mixed)
Changes in bowel habits compared to baseline
Any mucus or blood in stool
Relationship of symptoms to meals, stress, or other triggers
Quality of life: Impact of IBS on daily activities and overall well-being
Previous treatment history:
Medications for IBS (antispasmodics, laxatives, antidiarrheals)
Dietary modifications
Stress management techniques
Objective:
Vital Signs: (BP, HR, RR, Temp)
Physical Exam:
Abdominal examination: Tenderness, distension, guarding
Digital rectal exam (if indicated)
Assessment:
Irritable Bowel Syndrome (IBS) subtype (IBS-D: diarrhea-predominant, IBS-C: constipation-predominant, IBS-M: mixed) based on Rome criteria
Severity of IBS symptoms
Potential contributing factors (stress, dietary factors, motility issues)
Plan:
Dietary management:
Review dietary triggers and recommend a low FODMAP diet trial if appropriate.
Encourage a high-fiber diet with gradual fiber increase to manage constipation or diarrhea.
Discuss importance of adequate hydration.
Medication management:
Consider medications for symptom control based on IBS subtype (antispasmodics for pain, laxatives for constipation, antidiarrheals for diarrhea).
Stress management:
Recommend stress management techniques (cognitive behavioral therapy, relaxation techniques) to manage stress-related symptoms.
Referral: Consider referral to a gastroenterologist for further evaluation or management if:
Severe or uncontrolled symptoms
Bloody stools
Unexplained weight loss
Suspicion of other underlying conditions
Follow-up:
Schedule next appointment in [interval] weeks to assess response to treatment and adjust plan as needed.
Education:
Educate the patient on IBS, its symptoms, and management strategies.
Provide information on the low FODMAP diet and its potential benefits.
Discuss the importance of stress management and healthy lifestyle habits.
Encourage the patient to keep a symptom diary to identify triggers and track response to treatment.