**Problems**
1. Abdominal pain, bloating, and changes in bowel habits.
**Past Medical History**
1. History of irritable bowel syndrome (IBS).
**Endoscopy Summary**
1. Oct 2023, Colonoscopy, showed mild inflammation in the sigmoid colon.
**Radiology Summary**
1. Jul 2024, CT scan of the abdomen, unremarkable.
**Current Medications**
1. Loperamide 2mg as needed for diarrhoea.
**Previous Medications**
1. Mebeverine 135mg three times a day, stopped due to ineffectiveness.
**On Going Plan**
1. Stool sample for faecal calprotectin.
2. Continue Loperamide 2mg as needed.
3. Increase fibre intake and avoid trigger foods.
4. Follow up in 4 weeks.
I reviewed this man in clinic today. He presented with a history of abdominal pain, bloating, and changes in bowel habits. He reports experiencing 2-3 bowel movements per day, with loose stools. He reports that the pain is intermittent, located in the lower abdomen, and is relieved by passing stool. He also reports a history of irritable bowel syndrome (IBS). He had a colonoscopy in October 2023 which showed mild inflammation in the sigmoid colon. A CT scan of the abdomen in July 2024 was unremarkable. My recommendations are to order a stool sample for faecal calprotectin, continue Loperamide 2mg as needed, increase fibre intake and avoid trigger foods. I have arranged a follow up appointment in 4 weeks.
**Problems**
1. [Reason(s) for consultation, including specific gastrointestinal concerns or symptoms such as abdominal pain, dyspepsia, changes in bowel habits, gastrointestinal bleeding, jaundice, etc.] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Past Medical History**
1. [Relevant past medical history, including significant gastrointestinal or systemic conditions, surgeries, or other relevant details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Endoscopy Summary**
1. [Month (first 3 letters) and year of endoscopy, type of endoscopy and summary of findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Radiology Summary**
1. [Month (first 3 letters) and year of scan, type of scan and summary of findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Current Medications**
1. [Current medications, including any over-the-counter medications, supplements, and treatments for gastrointestinal or related conditions, with doses and frequencies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**Previous Medications**
1. [Previous medications, including any over-the-counter medications, supplements, and treatments for gastrointestinal or related conditions, with start and stop dates and reasons for discontinuation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
**On Going Plan**
1. [Investigations planned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
2. [Medications and dose and 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 male patient. If occupation is mentioned, include it as an adjective. Express in paragraph form starting with “I reviewed this man in clinic today” and ensure you include all articles such as ‘he’, ‘the’, ‘a’, and ‘an’. Make the text natural, fluent, and grammatically correct, resembling spoken English. Provide a summary of his gastrointestinal symptoms as explicitly described. Then summarise any gastrointestinal investigations that have been mentioned. Include the number of bowel movements per day and describe stool consistency, if stated. If pain is mentioned, include the nature, radiation, exacerbating and relieving factors as described. Summarise any other medical symptoms mentioned. Then, if a medical impression or diagnosis has been given, include it. 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 create, infer, or assume any patient details, diagnoses, or plans. Use only the transcript, contextual notes, or clinical note as the source of information. If a placeholder’s information is not explicitly mentioned, omit it silently without indicating omission. Never hallucinate or fabricate any clinical information.)
