Thank you for referring 62-year-old male for assessment regarding Irritable Bowel Syndrome (IBS).
He has been experiencing symptoms of IBS for approximately 6 months, including abdominal pain, bloating, and altered bowel habits, significantly impacting his daily life and ability to work.
He expressed a high level of motivation to make dietary changes to manage his symptoms.
Medical history includes hypertension, managed with medication, and a recent colonoscopy that ruled out any structural abnormalities. The colonoscopy was performed on 12 September 2024.
He lives with his wife, is retired, and has a strong support system.
Bowel habits are variable, with alternating episodes of constipation and diarrhoea. He reports occasional mucus in his stools.
Medications:
Lisinopril 10mg daily for hypertension.
Assessment:
Patient reports a typical Western diet with regular meal patterns, but often skips breakfast. He enjoys a variety of foods but avoids dairy due to perceived intolerance. A 24-hour recall revealed a high intake of processed foods and limited fibre intake. He reports food security.
His eating pattern shows a low intake of core food groups, particularly fruits, vegetables, and whole grains. He consumes a moderate amount of meat and meat alternatives.
He identifies several food triggers, including high-FODMAP foods such as onions, garlic, and apples, which exacerbate his symptoms.
He recently attempted a low-FODMAP diet for two weeks, with some improvement in symptoms, but found it difficult to adhere to.
He reports emotional eating, particularly when stressed, leading to increased consumption of trigger foods.
He reports moderate stress levels related to his health concerns, which appear to worsen his IBS symptoms.
Anthropometry:
Current weight: 85 kg, Height: 178 cm, BMI: 26.8 kg/m2.
He has experienced a slight weight gain of 2 kg over the past year.
Impression:
Patient presents with IBS, likely triggered by dietary factors. Recommendations include a modified low-FODMAP diet, focusing on identifying and eliminating trigger foods, increasing fibre intake gradually, and incorporating stress-reduction techniques. We will also focus on regular meal patterns and adequate hydration.
Review appointment suggested in 4 weeks.
Once again thank you for the referral, I look forward to assisting in the management of IBS.
Thank you for referring [insert age and gender] for assessment regarding [condition].
[Mention background to condition, including duration and impact on daily function if relevant.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
[Mention motivation level for change.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
[Mention medical history, including any relevant investigations and dates.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
[Mention social history, including living situation, occupation, and support system.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
[Mention bowel habits, including frequency, consistency and symptoms if applicable.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
Medications:
[Mention medications, supplements, and probiotics if applicable.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a single sentence or short paragraph.)
Assessment:
[Brief summary of diet history including meal patterns and areas for improvement. Include mention of food preferences, foods avoided, any special diet followed, 24-hour recall where available, and food security status.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in paragraph format.)
[Summary of eating pattern and representation of core food groups such as grains, fruit, vegetables, dairy, and meat or meat alternatives.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
[Detail food triggers identified in relation to symptoms and whether FODMAPs are present.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
[Note any recent changes to diet and reasons if applicable.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
[Describe physical and emotional eating behaviours if explored.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
[Include stress levels and their potential impact on eating or symptoms.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
Anthropometry:
[Mention current weight, height, and calculated BMI if available.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
[Include weight history and any recent changes including gains, losses, and stability.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
Impression:
[Summarise impression and recommendations in full sentences. Include broad dietary strategies or behaviour change approaches tailored to the patient's needs and current concerns.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
[Review appointment suggested in X weeks.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in full sentences.)
Once again thank you for the referral, I look forward to assisting in the management of [condition].
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank. Use full sentences and paragraph format as appropriate.)