Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint:
New or established microscopic colitis (MC)
(Specify) Chronic watery diarrhea (may be > 3 times/day) lasting for weeks or months
May mention urgency, fecal incontinence, abdominal cramping (less common)
History of Present Illness:
For new patients:
Duration and severity of diarrhea.
Stool characteristics (watery, bloody).
Abdominal pain or cramping (severity and location).
Nocturnal diarrhea.
Weight loss (uncommon but possible).
For established MC:
Follow-up since diagnosis and treatment.
Changes in bowel habits or symptoms.
Medication adherence and side effects.
Past Medical History:
Risk factors for microscopic colitis:
Age (more common in older adults)
Autoimmune diseases (e.g., Crohn’s disease, ulcerative colitis, celiac disease)
Use of certain medications (e.g., nonsteroidal anti-inflammatory drugs – NSAIDs)
Medications:
List all current medications, including NSAIDs, antibiotics, and anti-diarrheal medications.
Social History:
Smoking history (may worsen symptoms).
Family History:
Family history of inflammatory bowel disease (IBD) (not a strong risk factor for MC).
Physical Exam:
Normal or minimally tender abdomen in most cases.
Rectal exam: May reveal normal findings or mild urgency.
Laboratory Tests:
Complete blood count (CBC) and electrolytes: May be normal unless there is dehydration or malnutrition.
Stool tests: Usually negative for bacterial, parasitic, or viral pathogens.
C-reactive protein (CRP): May be elevated in some cases of microscopic colitis.
Imaging Studies (not routinely used but may be indicated in some cases):
Colonoscopy with biopsies: The definitive diagnostic test for MC. Biopsies reveal characteristic inflammatory changes in the colon lining despite a normal macroscopic appearance.
Abdominal imaging (CT scan or abdominal X-ray): May be used to rule out other causes of diarrhea, such as bowel obstruction or inflammatory bowel disease.
Assessment:
Microscopic colitis (lymphocytic or collagenous colitis): Based on clinical presentation, negative stool tests, and characteristic colonic biopsy findings (if available).
Severity of diarrhea: Evaluate the impact of diarrhea on daily life and consider complications (dehydration, malnutrition).
Plan:
Treatment:
Dietary modifications: May include eliminating NSAIDs (if used) and considering a low-fat, high-fiber diet.
Antidiarrheal medications: Loperamide for short-term symptom relief.
Budesonide (corticosteroid): The mainstay of treatment for moderate to severe MC.
Other medications: Immunomodulators (e.g., azathioprine) may be considered for refractory cases.
Monitor response to treatment with symptom improvement and stool frequency.
Consider repeat colonoscopy with biopsies in some cases to monitor response to treatment or if symptoms worsen.
Consultations:
Referral to a gastroenterologist may be indicated for complex cases or those not responding to initial therapy.
Education:
Educate the patient about microscopic colitis, symptoms, risk factors, and treatment options.
Discuss dietary modifications and potential benefits of a low-fat, high-fiber diet.
Provide resources for patient advocacy organizations specializing in digestive disorders.
Disclaimer: This template is for informational purposes only and should be adapted to the specific needs of each patient. Microscopic colitis can be a chronic condition, but with proper management, most patients experience significant improvement in their quality of life.