**On going plan**
1. Colonoscopy and biopsy scheduled.
2. Omeprazole 20mg once daily.
3. Avoidance of fatty foods and alcohol. Increase fibre intake.
4. Follow up in 6 weeks.
I reviewed this man in clinic today, 1 November 2024. He reported a significant reduction in his abdominal pain since starting the prescribed medication. He also mentioned that he has experienced some mild constipation. The findings of his recent colonoscopy revealed mild inflammation in the sigmoid colon. The biopsy results are pending. My recommendations include a repeat colonoscopy and biopsy, continuation of omeprazole 20mg once daily, avoidance of fatty foods and alcohol, and an increase in fibre intake. I have scheduled a follow-up appointment in 6 weeks to review the biopsy results and his progress.
**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 male patient. 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 sound natural and grammatically correct, like fluent spoken English. Provide an update on how he describes any changes in his symptoms since his last review, including any new symptoms if mentioned. Then summarise the findings of his recent gastrointestinal investigations, if explicitly mentioned. If a diagnosis has been given, include it; otherwise omit. Then summarise my recommendations in paragraph form, including the 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, assessments, 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.)