[doctor] brittany edwards , 07 , 1898 . she is a return visit for ibs with functional abdominal pain , nausea , vomiting . ms. edwards is a pleasant , 32-year-old female who was last seen in august of 2019 with flares of abdominal pain , who was diagnosed with irritable bowl that was treated with bentyl .
[doctor] she had a previous prescription for reglan that she received from the emergency room that she used as needed for nausea . she was instructed to start a low dose fiber supplement , such as citrucel , daily , probiotics to help with gas and bloating , bentyl up to four times daily for intestinal cramping , and stop reglan and use zofran as needed . neuromodulators such as elavil and buspar were discussed but not started .
[doctor] hello , how are you ?
[patient] i'm okay .
[doctor] good . how have you been feeling ?
[patient] not so good .
[doctor] yeah , so my nurse told me you have been going out to eat some on friday nights and saturday nights and that you have had some spicy foods or spicy shrimp .
[patient] yeah , i have .
[doctor] okay . well , your gut probably does not always appreciate that .
[patient] no , it does n't like it at all .
[doctor] yeah , so ibs is one of those things where you are very sensitive to certain things such as spicy foods or fatty foods and alcohol . and this can cause lower belly stuff like cramps , or you can get upper belly stuff such as nausea .
[patient] i've been getting both .
[doctor] okay . um , so how frequently have you been getting or having a bowel movement on normal days ?
[patient] i'm starting to notice it's between two and three times a day .
[doctor] okay . and are they soft stools or formed stools ?
[patient] um , they're formed .
[doctor] okay . and after you have gone out either drinking with your friends , do you tend to have more diarrhea ?
[patient] yeah , i do .
[doctor] okay . do you feel it's the food or the alcohol or both ?
[patient] uh , well usually we go to friday's restaurant . i always eat pasta , the chicken alfredo .
[doctor] okay . i can s- i can bet it's the alfredo sauce .
[patient] but it normally does n't bother me .
[doctor] okay . well , pasta can make you bloated , uh , but it does n't usually cause diarrhea . grilled chi- uh , grilled chicken is usually all right . alfredo , though , is higher in fat , and it does contain dairy . but you're saying it usually does n't bother you ?
[patient] no .
[doctor] okay . what type of alcohol drink do you drink when you are there ? is it a sweet drink ?
[patient] most of the time it's either tequila or dark liquor . i prefer patron , but if i get brown liquor , i only get two . um , every now and again , i'll drink a martini .
[doctor] sometimes it's the mixer they tend to put in the drinks , but it can be a variety of things . um , so when you're not eating out or drinking , what we do on a daily basis does help keep us regular , so when it does flare up , it c- it might not be as bad . um , have you had any luck using the fiber like citrucel regularly ?
[patient] um , no . i guess i need to find a new drink .
[doctor] okay . and how is it during the week ?
[patient] like what i eat ?
[doctor] yeah , and with the diarrhea and abdomal- um , abdominal pain .
[patient] right now , i'm still having the cramping and sharp pains , so i've been avoiding heavy foods . i did have some fried chicken today , though .
[doctor] and was everything all right after that ?
[patient] yeah , for the most part .
[doctor] okay . remember , it's also the portion sizes . so i mean , if you eat a little and you feel fine , then that's okay . you have to just really watch the portions .
[patient] okay , good . i ca n't go out- go without some fried chicken at least once in a while .
[doctor] sounds good . all right , well let's take a look at you today , and we'll do a brief physical exam . you will hear me call out some findings . i will answer any questions , and we will discuss once we have finished the exam .
[patient] sounds good .
[doctor] all right . so the patient is alert and cooperative , appears stated age . all right . i'm going to listen to your heart and lungs . and lungs are clear to auscultation bilaterally . heart regular rate and rhythm . all right , so if you could just lay back for me , and i'll examine your abdomen .
[patient] okay .
[doctor] all right . do you have any tenderness ?
[patient] no , not really .
[doctor] okay . so the abdomen is soft , non-tender . no masses or organomegaly . and let me take a listen . normal active bowel sounds . all right . you can go ahead and sit up now . thank you .
[doctor] all right , so first i want you to try citrucel . it does come in a tablet . you should use it twice daily for regularity . then i would say , if you know you're going out and will possibly have diarrhea as a result , you can go ahead and use your bentyl 20 milligrams . you can do one tablet before you eat , and then repeat up to four times daily . and then on days when you feel good , you do n't have to use anything . um , and then on friday before you leave the house , you can take a bentyl and put one in your pocket for later , and then you can repeat the same thing on saturday if you want , and that will be totally fine .
[patient] okay , that sounds good .
[doctor] okay . and so your bentyl , that's the anti-spasm medication , and i would take the higher dose .
[patient] can i get a refill of that ?
[doctor] yes , absolutely . uh , so take one tablet about 30 to 45 minutes before leaving the house and then the second tablet at the restaurant . then with the nausea , um , i think we should try and see if you can recognize a pattern with what you are eating and drinking , um , um , about , like , what makes it worse .
[patient] yeah , i noticed i've been doing better with drinking water instead of sodas .
[doctor] okay , good . and then for your zofran , i would n't take that ahead of time . just plan on drinking plenty of water .
[patient] okay .
[doctor] okay , and you can take it , but before you do , we want to try to reduce the triggers . uh , so watch out for greasy or fatty foods and sugary drinks .
[patient] okay , i can do that .
[doctor] okay . and so , however , if it is not just these isolated inci- incidents and the symptoms are happening all the time , we could put you on a long term medication that would take ... that you would take every night . and so then you do n't have to use so much bentyl or the zofran . how do you feel about that ?
[patient] i was actually going to ask you about something like that to help avoid flares altogether .
[doctor] yeah , there is . and it actually works on the chemicals in your brain that are causing your gut to be overly sensitive . one is called elavil , but the only drawback is that it can make you a little sleepy . how does that sound ?
[patient] that sounds like a much better plan .
[doctor] okay , great . we can definitely do that . uh , just take it every night before bedtime .
[patient] okay , that sounds good . thank you so much .
[doctor] you're welcome . and so i have gone ahead and sent your prescriptions to your pharmacy . just give us a call if you have any questions or need us for anything else . and then let's plan on touching base through mychart email in about a month to just check in to see how you're doing with symptoms . okay ?
[patient] okay , that sounds good . thank you .
[doctor] you're welcome , and have a good rest of your day .
[doctor] so review of symptoms is positive for diarrhea , nausea , and abdominal pain . assessment and plan . brittany edwards is a pleasant female with ibs and functional abdominal pain , aggravated by high stress , poor eating habits , and poor sleeping habits . i've encouraged dietary and lifestyle modifications , as well as starting a neuromodulator such as elavil 25 milligrams at bedtime for ibs .
[doctor] she can use bentyl 20 milligrams as needed 30 to 45 minutes prior to eating out at a restaurant . she can also use zofran if needed . however , i have encouraged her to reduce greasy and fatty foods and alcohol consumption . i have asked her to follow up in one month by emailing over mychart regarding any side effects and issues , or issues with elavil or if adjustments are needed .

Medical orders:
description: up to four times daily one tablet milligrams bentyl 20 as needed 30 to 45 minutes prior to eating out at a restaurant .
order_type: medication
reason: anti-spasm
description: elavil 25 milligrams bedtime
order_type: medication
reason: ibs