New Male General Outpatient review

**Problems** 1. Abdominal pain, bloating, and changes in bowel habits. **Past Medical History** 1. History of irritable bowel syndrome (IBS). **Endoscopy Summary** 1. Oct 2023, Colonoscopy, showed mild inflammation in the sigmoid colon. **Radiology Summary** 1. Jul 2024, CT scan of the abdomen, unremarkable. **Current Medications** 1. Loperamide 2mg as needed for diarrhoea. **Previous Medications** 1. Mebeverine 135mg three times a day, stopped due to ineffectiveness. **On Going Plan** 1. Stool sample for faecal calprotectin. 2. Continue Loperamide 2mg as needed. 3. Increase fibre intake and avoid trigger foods. 4. Follow up in 4 weeks. I reviewed this man in clinic today. He presented with a history of abdominal pain, bloating, and changes in bowel habits. He reports experiencing 2-3 bowel movements per day, with loose stools. He reports that the pain is intermittent, located in the lower abdomen, and is relieved by passing stool. He also reports a history of irritable bowel syndrome (IBS). He had a colonoscopy in October 2023 which showed mild inflammation in the sigmoid colon. A CT scan of the abdomen in July 2024 was unremarkable. My recommendations are to order a stool sample for faecal calprotectin, continue Loperamide 2mg as needed, increase fibre intake and avoid trigger foods. I have arranged a follow up appointment in 4 weeks.