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1. CHIEF COMPLAINT
2. HPI
a. Concern:
b. Onset-
•Sudden
•Gradual
c. Duration: ____
•Recent
•A few days
•Many days
•A few weeks
•Many weeks
•A few months
•Many months
•A few years
•Many years
•Recurrent
•N/A.
d. Severity:
•Mild
•Moderate
•Severe
•Absent
•Normal
•Increased
•Decreased
•Stable
•No significant change from prior visit.
•Details
g. Quality :
•Improving
•No change
•Worsening
•Burning pain
•Constricting
•Crushing
•Dull pain
•Heavy
•Sharp pain
•Squeezing
•Stabbing
h. Frequancy
i. Status
j. Context
k. Aggravated by : Meals
l. Relieved by : Defecation
m. Associated Symptoms
•Clear or white mucorrhea
•Dyspepsia
•Heartburn
•Nausea
•Vomiting
•Dyspareunia
•poor libido
•urinary frequency
•urinary urgency
•Anorexia or weight loss
•Fever
•Rectal bleeding
•Steatorrhea
•Lactose and/or fructose intolerance
•Gluten intolerance
n. Pertinent Negatives
o. Notes
3. ROS
4. SYMPTOMS
o Constipation
o painful defecation
o infrequent defecation
o Diarrhea
o Postprandial urgency
o Abdominal pain
o Abdominal distention
o Clear or white mucorrhea
o Dyspepsia
o Heartburn
o Nausea
o Vomiting
o Dyspareunia
o poor libido
o urinary frequency
o urinary urgency
o Anorexia or weight loss
o Fever
o Rectal bleeding
o Steatorrhea
o Lactose and/or fructose intolerance
o Gluten intolerance
5. HISTORY
a. FAMILY HISTORY
•Diabetes
•Hypertension
b. SOCIAL HISTORY
•Smoking
6. ALLERGIES
7. PHYSICAL EXAMINATION
• The patient was tense or anxious.
• The patient was present with sigmoid tenderness or a palpable
sigmoid cord.
9. TESTS TO BE ORDERED
•CBC
•Comprehensive metabolic panel
•Hemoccult test
•Stool examinations:
•Breath testing
•Thyroid function tests
•Serum calcium
•Erythrocyte sedimentation rate
•C-reactive protein
•Small bowel biopsy
•H2 breath test
•Upper GI barium study
•Double-contrast barium enema
•Gallbladder ultrasonography
•Abdominal CT scan
•Anal manometry
•Endoscopy
•Esophagogastroduodenoscopy
•Colonoscopy
10. ASSESSMENT/PLAN
•Psychiatric counseling for patients with anxiety
•Cognitive behavioral therapy
11. EDUCATION
•Fiber supplementation may improve symptoms of constipation
and diarrhea.
•Take Polycarbophil compounds
•Take judicious water Avoid caffeine Avoid legume
•Avoid or limit lactose and/or fructose
•Take supplement calcium
12. MEDICATION
•Dicyclomine hydrochloride
•Hyoscyamine sulfate
•Diphenoxylate hydrochloride
•Loperamide
•Imipramine
•Amitriptyline
•Cisapride monohydrate
•Tegaserod
•Alosetron
•Lubiprostone
•Methylcellulose
•Psyllium
13. FOLLOW UP