**Problems**
1. Abdominal pain, bloating, and changes in bowel habits.
**Past Medical History**
1. Irritable Bowel Syndrome (IBS) diagnosed 5 years ago. Appendectomy 10 years ago.
**Endoscopy Summary**
1. Oct 2023, Colonoscopy, revealed mild inflammation in the sigmoid colon.
**Radiology Summary**
1. Jul 2024, CT scan of abdomen and pelvis, unremarkable.
**Current Medications**
1. Loperamide 2mg as needed for diarrhoea.
**Previous Medications**
1. Mebeverine 135mg three times a day, stopped 6 months ago due to ineffectiveness.
**On Going Plan**
1. Colonoscopy.
2. Loperamide 2mg as needed.
3. Increase fibre intake, avoid trigger foods.
4. Follow up in 3 months.
I reviewed this woman in clinic today. She presented with a history of abdominal pain, bloating, and changes in bowel habits. She reports having 2-3 bowel movements per day, with loose stools. The pain is described as cramping in nature, located in the lower abdomen, and is exacerbated by eating and relieved by passing stool. She underwent a colonoscopy in October 2023, which revealed mild inflammation in the sigmoid colon. She also had a CT scan of her abdomen and pelvis in July 2024, which was unremarkable. I have recommended a colonoscopy. I have prescribed Loperamide 2mg as needed. I have advised her to increase her fibre intake and avoid trigger foods. I have recommended a follow-up appointment in 3 months.
**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 gastrointestinal or systemic conditions, surgeries, and other significant medical 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, including 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 & 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 female patient. Express in paragraph form starting with “I reviewed this woman in clinic today,” and ensure you include all articles such as ‘she’, ‘the’, ‘a’, and ‘an’. If a career or occupation is mentioned, include it as an adjective. Make the text sound natural and grammatically correct, like fluent spoken English. Provide a summary of her gastrointestinal symptoms as explicitly 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 exactly as described. Summarise any gastrointestinal investigations that have been mentioned. Then summarise any other medical symptoms she reports. If a medical impression or diagnosis has been mentioned, include it; otherwise omit. Then summarise my recommendations in paragraph form including the investigations planned, the medications prescribed, the 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, assessments, 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.)
