Abdominal Pain

Patient Name: Jane Smith

Date of Birth: 08/15/1980

Gender: Female

MRN #: 987654321

Date of Service: 04/07/2024

Chief Complaint

• Abdominal pain and bloating

History of Present Illness

Ms. Smith is a 43-year-old female presenting with complaints of intermittent abdominal pain and bloating for the past two months. She describes the pain as crampy, primarily in the lower abdomen, and is associated with occasional diarrhea. She reports no significant changes in her diet or bowel habits. She denies any fever, nausea, vomiting, or blood in stool.

Past Medical History

• Irritable bowel syndrome (IBS)
• Seasonal allergies

Medications

• Over-the-counter antihistamines for seasonal allergies
• Probiotics for IBS symptoms

Allergies

• None known

Social History

• Non-smoker
• Occasional alcohol use

Family History

• Mother had a history of IBS

Review of Systems

• Negative for unintentional weight loss
• Negative for night sweats or fevers
• Positive for increased gas and bloating after meals

Physical Examination

• General: Alert and cooperative, in no acute distress
• Abdomen: Soft and non-tender, no palpable masses or organomegaly, normal bowel sounds

Assessment and Plan

1. Irritable bowel syndrome (IBS): Continue current management with dietary modifications, stress reduction techniques, and probiotics. Consider adding a fiber supplement to help with bowel regularity.
2. Symptomatic relief: Prescribe an antispasmodic medication (e.g., dicyclomine) to help alleviate abdominal cramping.
3. Follow-up: Schedule a follow-up appointment in four weeks to assess response to treatment and make any necessary adjustments.

Electronically signed by [Provider's Name], MD. Date: 04/07/2024. Time: 11:30.