**On going plan**
1. Colonoscopy scheduled for 15 November 2024.
2. Lansoprazole 30mg once daily.
3. Advised to avoid high-fibre foods and to maintain a regular exercise routine.
4. Review in 3 months.
I reviewed this lady in clinic today, 1 November 2024. She has been under follow up for ongoing investigation of her gastrointestinal symptoms. She reports that her abdominal pain has improved slightly since her last review, but she is still experiencing intermittent bloating. The results of her recent colonoscopy revealed mild inflammation in the sigmoid colon. She reports that her symptoms are affecting her ability to concentrate at work. The diagnosis is Irritable Bowel Syndrome (IBS). I have recommended a colonoscopy, prescribed Lansoprazole, advised her to avoid high-fibre foods and to maintain a regular exercise routine, and scheduled a follow-up appointment in three months.
**On going plan**
1. [Investigations planned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
2. [Medications & dose & frequency prescribed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
3. [Lifestyle recommendations in brief] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
4. [Follow up recommendations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[This letter relates to a female patient. Express in paragraph form starting with “I reviewed this lady in clinic today” and ensure you include all articles such as 'she', 'the', 'a', 'an' etc. Make the text sound natural and grammatically correct, like fluent spoken English. Describe that she has been under follow up for a summary of her gastrointestinal symptoms using pronouns like ‘she’. Provide an update on how she describes any changes in her symptoms since her last review, and include any new symptoms if explicitly mentioned. Summarise the findings of her recent gastrointestinal investigations, if they have been mentioned. Then summarise any other symptoms that she may have reported, and describe how her social and work life may or may not be affected by her health. Then summarise the diagnosis that she has been given (if one has been mentioned; otherwise omit). Finally, summarise my recommendations in paragraph form including investigations planned, medications prescribed, lifestyle recommendations (in brief), and follow up recommendations.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in the transcript, contextual notes, or clinical note; otherwise omit section entirely. Never come up with or infer patient details, assessments, plans, or interventions. Use only the transcript, contextual notes, or clinical note as the source of information. If any placeholder’s information is not explicitly mentioned, omit it silently without indicating omission. Never hallucinate or fabricate clinical information.)