Dani is a 19-year-old female who is seen in the office complaining of problems with my bowels. She is having frequent abdominal cramping, flatulence, and feels bloated most of the time. She describes alternating bouts of constipation and diarrhea, though more diarrhea than constipation. On questioning, she did acknowledge mucus in her stools, though she denied any blood.
On physical exam, her abdomen was, indeed, bloated. Digital rectal examnegative. Hyperactive bowel sounds on auscultation.
I explained to Dani, that based on her symptoms and exam, she most likely has irritable bowel syndrome and I would like to start out with a conservative approach. I would like her to keep a food diary for the next seven days and document what she eats and when. I also want her to document her mood and activity for each day. She was also instructed to keep a record of each bowel movement, by day, and to indicate if it was constipated, diarrhea, normal, etc. I would also like her to increase her fiber.
Plan: See her back in the office in 10 days and then I will decide whether to start her on medications or do further work up.
Dx: IBS
What will be an ideal response?
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