Issues List (custom)

Gastroenterology Clinic Note Age and level of supports (iADL/ dependant ADL) 67, iADL Occupation : Retired teacher Reason for referral : Abdominal pain, change in bowel habits, weight loss PMHx - Hypertension, Hyperlipidemia, Appendectomy 2005, Atorvastatin 20mg daily, Lisinopril 10mg daily Medications - Atorvastatin 20mg, Lisinopril 10mg, Omeprazole 20mg 1. Abdominal pain - Colonoscopy 20/10/2024 showed mild diverticulosis. CT Abdomen 25/10/2024 showed no acute findings. Change in bowel habits - Stool sample 27/10/2024 negative for blood and parasites. On review/ - Patient reports intermittent abdominal pain, mostly in the lower left quadrant. Reports alternating constipation and diarrhoea. States he has lost 5kg in the last 3 months. No nausea or vomiting. - BP 130/80, HR 78, Abdomen soft, non-tender, mild tenderness in the LLQ. Bowel sounds present. Impression/ - Irritable bowel syndrome, Diverticular disease, possible malignancy. Plan/ - Repeat colonoscopy in 6 months. Consider further blood tests including CEA if symptoms persist. - Increase fibre intake. Consider a trial of antispasmodics. Discuss lifestyle modifications. - Refer to dietician for dietary advice.