Gas and bloating

The patient comes in today for an initial consultation for ALCAT testing. Her primary complaint is after meals, she notices severe gas and bloating. She has associated diarrhea alternating with constipation. She has acid reflux frequently associated with meals. She has had these symptoms for years and it is progressively getting worse. She has been taking lactate enzymes as she does know that she is lactose intolerant, that she has symptoms despite the lack of dairy products. She has had weight gain of 20 pounds as well despite diet and exercise. She did lose a few pounds. She also has muscle aches pains intermittently. She has stomach aches and pains. She rates her pain as 5/10 on a visual analog scale. She has trouble digesting food, sore throat, watery eyes, stuffy nose, few cravings, binge eating, water retention, fatigue, and lethargy. She has undergone testing for celiac disease and allergy testing.

DIAGNOSES:
787.3 Gas and bloating.
536.8 Dyspepsia.
564.1 Irritable bowel syndrome.
278.0 Weight gain.
530.1 Gastroesophageal reflux.
729.1 Myalgias.

RECOMMENDATIONS:
We will recommend comprehensive ALCAT testing for the patient’s symptoms. Her ALCAT food and chemical sensitivity survey score was 31. Venipuncture was performed today and sent to lab. We will see her back in two weeks to follow with a nutritionist for dietary planning and review of results.

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