Diagnosis: Irritable Bowel Syndrome
Differential Diagnosis: Lactose Intolerance, and Celiac disease.
Include ICD-10 Code for diagnosis
Attached is template. use template exactly they way it is. Be sure to bold abnormal findings.
References no older than 3 years
NO COVER PAGE
THE HISTORY AND PHYSICAL (H&P)
- Chief Complaint
“I have abdominal pain, diarrhea, and constipation.”
- History of Present Illness (HPI)
B.J. is a 36-year-old Hispanic female who has reported to the clinic for the first time. Her chief complaint is a combination of symptoms including abdominal pain, diarrhea, and constipation. B.J. has reported that she has been having persistent abdominal pain for the past one week. The pain was not triggered by any food or drug consumed in the recent past. She indicates that nothing alleviates her abdominal pain. Her last physical exam was in January 2020.
Location: Abdomen.
Quality: Aching pain.
Quantity or severity: Severe pain. 6/10 on the pain scale.
Timing: 1 week or 7 days.
Setting: Persistent.
Aggravating or relieving factors: Not known.
Associated manifestations: Diarrhea and constipation.
III. Past medical history (PHx)
- Childhood illnesses
As per available medical records, B.J. was hospitalized due to pneumonia complications at the age of 2 years. She was also treated several times of cold and flu.
- Immunizations
B.J. received diphtheria, pertussis, and tetanus (DPT) vaccine during childhood. Her last tetanus booster was given at the age of 16 years. She lastly received influenza vaccine at the age of 18 years. B.J. has not been vaccinated against COVID-19.
- Adult Illnesses
B.J. was hospitalized at the age of 27 years due to complications of a knee injury she suffered while working on the farm. As per the available medical records, B.J.’s knee bone was displaced and she had to be hospitalized. She recovered and was discharged then. She has never been hospitalized again since then except at the time of delivery.
- Operations
B.J. delivered her twin daughters through a Caesarian section. She denies experiencing other complications during delivery as she was able to recover successfully.
- Allergies
No known drug or food allergies reported.
- Medications
Tylenol for stomachache.
- Complimentary treatments
B.J. is not using any complementary treatments at the moment.
- Family history
Father died of stroke complications five years ago at the age of 80 years. B.J.’s mother is alive and has not been diagnosed with any serious medical condition. She is 72 years old. She does not have any information about her paternal grandparents. However, she indicates that her maternal grandparents died when she was still young. She is not aware of their causes of death. B.J. is the third born in a family of five: 4 girls and 1 boy. All her siblings are healthy. She has two twin daughters aged 6 years. Both of them are healthy.
- Social history
B.J. has a certificate in front office operations. She is currently employed as a receptionist at a city hotel. Her husband is a manager in a nearby factory. B.J. and her family occasionally travels during holidays. She denies consuming alcohol or cigarettes. She does not use illicit substances such as heroin and cocaine. B.J. is sexually active. She denies using any hormonal contraceptives but admits using condoms as the only mode of contraception. B.J. typical diet comprises snacks and boiled milk for breakfast, fried potatoes for lunch, and mostly cereals, white meat, ugali, and vegetables for dinner. She does not eat red meat but she denies having any issues when she consumes it.
- Review of Systems
General: Reports abnormal weight loss. Denies nausea, vomiting, or fever. Reports severe abdominal pain that is also characterized by diarrhea and constipation.
Skin: Denies hair loss or thinning. No bruises, pruritus, redness, or rashes on the skin reported. Does not report brittle nails or nail breakage.
HEENT:
Head: Denies physical head injury. Denies a headache.
Eyes: Does not report redness and pain in the issues. No vision issues reported. Does not report a history of cataracts. Denies using contact glasses. Does not report double vision or excessive tearing.
Ears: Denies ear pain, hearing loss, ear infection, or hearing in the ears.
Nose and sinuses: No nasal stuffiness reported. Does not report nasal discharge or obstruction. No recent changes in smell reported. Denies a history of nasal infections.
Mouth and throat: No mouth ulcers, pain, or dryness reported. Denies hoarseness of the throat. Denies a history of mouth or throat infections.
Neck: Denies pain in the neck region. Does not report swollen lymph nodes. Denies goiter or neck lumps.
Lymphatics: No axillae or swollen lymph nodes in the neck region reported.
Breasts: Denies masses or lumps on the breasts. Denies nipple pain or discharge.
Pulmonary: Does not report difficulty breathing. Denies a cough. No hemoptysis reported. Denies pleuritic chest pain, wheezing, or cyanosis. Does not report a history of recurrent pneumonia or tuberculosis.
Cardiovascular: Denies chest pain, shortness of breath, irregular heartbeat, or heart murmurs. Denies a history of cardiovascular disease such as ischemic attack. B.J. has never been diagnosed with high blood pressure before.
Gastrointestinal: Reports abdominal pain, constipation, and diarrhea. Does not report dysphagia, or heartburn. Denies vomiting or nausea. Reports changes in bowel movements. No excessive belching or a history of gallbladder problems reported.
Urinary: Denies the presence of blood in urine or hematuria. Denies dysuria. Does not report a reduction in urine volume. B.J. denies a history of urinary tract infections. Denies a history of kidney stones, urinary incontinence, or nocturia.
Genital tract (female): Age of menarche was at 13 years. Her last menstrual period was a week ago on 25th November 2021. Her menstrual cycle is 27-28 days with normal bleeding. Denies postcoital bleeding. Denies pain during intercourse, vaginal discharge, vaginal pruritus, or infertility. Denies a history of a sexually-transmitted disease. She has never undergone a Pap smear before.
Musculoskeletal: Denies joint stiffness or pains. No joint swelling, joint tenderness, backache, limitations of motion, or a history of fractures reported.
Neurologic: Denies seizures, tingling, tremors, or numbness of limbs. Denies headaches muscle atrophy, dizziness, or memory changes.
Psychiatric: Denies nervousness, depression, insomnia, anxiety, or insomnia. Denies suicidal ideation.
Endocrine: Denies heat or cold intolerance. No excessive thirst, abnormal sweating, or excessive hunger reported. Does not report thyroid trouble or excessive urination.
Hematologic: B.J. denies anemia, easy bruising, or uncontrolled bleeding. Does not report a history of blood-related disorders such as sickle-cell disease.
VII. Physical examination
Vital signs: Blood pressure; 198/80, temperature; 37.1 degree Celsius, pulse; 90 beats per minute, respiratory rate; 18 breaths per minute, weight; 158.4 pounds.
General appearance: B.J. presents with discomfort caused by her abdominal pain. She is bending forward to try and reduce the pain. She is well-groomed and neatly dressed. B.J. is oriented to time, place, and person.
Skin: Skin is without rashes, sores or lesions. It is warm, intact, and dry. No cyanosis observed on the nail beds.
HEENT:
Head: The head is normocephalic and without trauma. It lacks evidence of palpable masses, scarring, or depressions. Hair is evenly distributed on the scalp and of normal texture.
Eyes: No evidence of discharge. Eyelids are normal in appearance without swelling or lesions. Cornea is not opacified. Conjunctivae are clear without exudates or hemorrhage. Sclerae is non-icteric. Visual acuity is 20/20.
Ears: The external ear and ear canal are non-tender without edema. The ear canal is clear without discharge. No signs of ear blockage. The tympanic membrane is pale grey in color in both ears.
Nose: No evidence of enlarged turbinates. Nasal mucosa is pink, hairy, and moist. No evidence of nasal tenderness. The nasal septum is positioned midline.
Throat: Oral mucosa is without sores, lesions, or ulcers. It is pink and moist with good dentition. Throat is non-erythematous. The pharynx is pink in appearance. No evidence of tonsillar exudates, edema, or pharyngeal injection.
Neck: Midline-positioned trachea. Absence of unusual masses or pulsations. No jugular venous distention. Thyroid is palpable.
Nodes: No swelling of the inguinal, axillary, or epitrochlear nodes.
Breasts: Palpation and inspection of both breasts does not reveal tenderness, discharge, or masses.
Chest: No evidence of deformities on inspection. Normal breath sounds, wheezes, crackles, rubs, or rhonchi on auscultation. No fremitus detected on palpation.
Heart: Visible PMI on inspection. Normal heart rate, S1, S2, without galloping, murmurs, or rubbing. Normal heart rhythm, no heaves, lifts, or excitement. No evidence of edema on the periphery. Varied bilateral peripheral pulses, capillary refill less than 3 seconds.
Abdomen: Bowel sounds heard. No scars. Abdominal tenderness present. Bloating and abdominal distention observed.
Back/spine: No mobility challenges. No evidence of deformities on the neck and back. No curvature. No CVA tenderness.
Extremities, including exam of pulses: No tremor, deformities, or swellings in upper and lower extremities. No evidence of joint tenderness or effusion.
Genitalia/Rectal: No lesions on external genitalia, pubic hair evenly distributed. No evidence of vaginal inflammation or discharge. No evidence of rectovaginal issues.
Neurologic:
Mental status: B.J. lack concentration and attentiveness. Her speech is normal and does not present with any signs of memory loss.
Cranial nerves: Crania nerves II-IX have full EOM’s. They are intact with evidence of visual fields.
Motor: Muscle rigidity absent. Normal gait and good balance. Muscle strength on all joints is 5/5.
Sensory: Reflexes are 2+. Light touch and pricking has revealed sensitivity in lower and upper limbs.
VIII. Problem list
Patient B.J. is a 36-year-old Hispanic female who has reported to the clinic complaining of abdominal pain, diarrhea, and constipation. According to B.J., these symptoms have lasted for the past one week. The pain was not triggered by any food or drug consumed in the recent past. She indicates that nothing alleviates her abdominal pain. The problematic symptoms that should guide the clinician when making a decision regarding the patient’s diagnosis include; persistent and severe abdominal pain that also occurs with diarrhea and constipation. From the review of systems, B.J. has reported changes in bowel movements without excessive belching. From physical exam, B.J.’s abdominal assessment results have revealed the presence of bowel sounds, abdominal tenderness, bloating, and abdominal distention.
- Differential diagnosis
- Irritable Bowel Syndrome (primary diagnosis)
ICD 10 code: K58.0: Irritable bowel syndrome with diarrhea.
- Lactose Intolerance
ICD 10 code: E73: Lactose intolerance
- Celiac disease
ICD 10 code: K90.0: Celiac disease
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2019). Seidel’s guide to physical examination (9th ed.). St. Louis, MO: Elsevier Mosby.
Bickley, L. (2018). Bates guide to physical examination and history taking (12th ed.). Philadelphia, PA: Wolters Kluwer.
Caio, G., Volta, U., Sapone, A., Leffler, D., Giorgio, R., Catassi, C. & Fasano, A. (2019). Celiac disease: a comprehensive current review. BMC Medicine, 17, 142. https://doi.org/10.1186/s12916-019-1380-z
Camilleri, M. (2021). Diagnosis and treatment of irritable bowel syndrome: A review. JAMA, 325(9):865-877. doi: 10.1001/jama.2020.22532.
Catanzaro, R., Sciuto, M. & Marotta, F. (2021). Lactose intolerance: old and new knowledge on pathophysiological mechanisms, diagnosis, and treatment. SN Comprehensive Clinical Medicine, 3, 499–509. https://doi.org/10.1007/s42399-021-00792-9.
Rachna, J. & Yogesh, J. (2021). The importance of physical examination in primary health care provided by NPHW is being threatened in COVID19 times. Journal of Family Medicine and Primary Care, 10(1), 19-21 doi: 10.4103/jfmpc.jfmpc_1932_20