CHIEF COMPLAINT

Hematochezia
History of Present Illness
4 days PTA:
 Ate a lot of Guyabano fruit
 5 hours later - onset of loose watery stools, bloody in
character with no other associated symptoms, drank water
to hydrate
 Total of 3-4 episodes per day.
 No medications were taken, no consult was done, patient
tolerated his condition.
History of Present Illness
1 day PTA:
 Symptoms improved and decided to have his stool sent to labs
for stool exam, results revealed presence of blood in his stool
 Contacted their family physician and was advised for
admission and colonoscopy, thus this admission.
Past Medical History

Hyprtension (2013)
- maintenance medications:
Amlodipine 100 mg/tab, 1 tab OD
Atorvastatin 40 mg/tab, 1 tab OD

Gout (2013)
- maintenance medications:
Allopurinol 300 mg/tab, 1 tab OD


DM T2 NIR- Diet Controlled

NO asthma

NO past surgeries

Has prior hospitalization at Kaiser Hospital, California USA
Personal and Social History
 Retired cook
 Lives with his wife
 22 years smoker: 66 pack years
 Completed 2 doses of ____ vaccine. No booster
 Review of Systems
 General Survey: (-) Fever, (-) Dizziness, (-) Fatigue, (-) Weight loss
 Skin: No rashes or other changes
 HEENT: (-) Headache, (-) tinnitus
 Respiratory: (-) Cough, (-) Tachypnea, (-) Dyspnea, (-) wheezing
 CVS: (-) Tachycardia/Bradycardia, (-)Murmurs, (-) palpitations
 Gastrointestinal: (-) Abdominal pain, (-) Vomiting
 GUS: (-) Flank pain, (-) Dysuria
 Rectal: (-) pain during passage of stools
 Extremities: (-) Edema
 Physical examination
General: patient seen and examined awake, afebrile, coherent not in
respiratory distress with the following vital signs:
V/S:
 BP: 130/80 mmhg
 HR: 86 bpm
 RR: 19 cpm
 O2Sat: 99% room air

Skin: no leisons , no jaundice, no cyanosis, warm to touch

HEENT: anicteric sclerae, pink palpebral conjunctiva ,no naso aural

discharges, tongue midline, oral mucosa pink

C/L: equal chest expansion, clear breath sounds

 Physical examination
CVS: adynamic precordium , distinct heart sounds , regular rate and rhythm , no
murmurs

Abdomen: Flabby, no leisons, normoactive bowel sounds, non tender

Rectal: (+) Fecal blood, (+) Hemorrhoids Grade 2

Extremities: no edema, no gross deformities, strong peripheral

Pulses, CRT <2sec
THANKS