Gastroenterology Consult

Reason for consultation: Chronic abdominal pain and changes in bowel habits. History of Present Illness: Mr. John Smith, a 45-year-old male, was referred by Dr. Thomas Kelly. He presents with a 6-month history of intermittent abdominal pain and recent changes in bowel habits, including episodes of diarrhea and constipation. He reports occasional nausea and a 5 kg weight loss over the past two months. Previous treatments included dietary modifications and over-the-counter antacids, with minimal relief. Past Medical History: Appendectomy at age 20. Medications: Omeprazole 20 mg daily, Multivitamin supplement. Allergies: No known drug allergies. Social History: Mr. Smith is a non-smoker and consumes alcohol socially. He works as an accountant. Family History: Father had colon cancer diagnosed at age 60. Physical Exam: Abdomen: Mild tenderness in the lower quadrants, no rebound tenderness, normal bowel sounds. Investigations: - Laboratory results: Normal CBC, elevated CRP. - Colonoscopy results: Diverticulosis noted, no polyps or malignancy. - Upper endoscopy results: Mild gastritis. - Imaging results: Abdominal ultrasound showed no significant findings. Assessment and Plan: 1. Chronic Abdominal Pain and Altered Bowel Habits Assessment: Likely irritable bowel syndrome (IBS) given the symptom pattern and absence of alarming features. - Investigations planned: Consider small bowel imaging to rule out other pathologies. - Medical treatment planned: Start on a low-dose tricyclic antidepressant for pain modulation. - Lifestyle modifications: Advise on a high-fiber diet and regular physical activity. - Follow-up appointments: Review in 6 weeks to assess response to treatment. - Relevant referrals: Consider referral to a dietitian for dietary management. Additional Notes: - Patient education on IBS, emphasizing the chronic nature of the condition and the importance of lifestyle modifications. - Instructions for symptom monitoring and when to seek immediate care, such as in cases of severe pain or rectal bleeding. - Addressed concerns about potential hereditary risk of colon cancer, advised on regular screening given family history.