1-1 PATIENT NOTE: DIARRHEA HISTORY: Describe the history you just obtained from this patient.

Include only information (pertinent positives and negatives) relevant to this patients problem(s). HPI: 25 yo male c/o diarrhea and bloody stool for 3 days. Blood in stool with each bowel movement, patient notes drops of blood prior to defacation, and burning during defacation. One bowel movement or less a day for 10 years. Diarrhea began one month ago and has loose watery stool at least one time a day, with rectal spasms. Abdominal pain, 8/10, began 2 days ago, sharp, constant, atleast two times a day. Diet consists most of junk food, no appetite changes, lost 10 lbs in a week. Exercise each day walks one mile. ROS: negative except as noted above Allergies: none Medications: prior use of OTC laxatives Pmh: pneumonia 2 years ago, hospitalized for 1 week. Psh: hemorrhoids removed 2 years ago Fh: parents alive and well, sister died of breast cancer 5 years ago Sh: denies tobacco, etoh, or drug use, lives alone, works as a librarian PHYSICAL EXAM: Describe any positive and negative findings relevant to this patients problem(s). Be careful to include only those parts of examination you performed in this encounter. The patient is in no acute distress and vitals are within normal limits. The breath sounds are clear bilaterally. The heart sounds are normal with no rubs, gallops and murmurs. The abdomen has bowel sounds and tenderness in the periumbilical area. DATA INTERPRETATION: Based on what you have learned from the history and physical examination, list up to 3 diagnoses that might explain this patients complaint(s). List your diagnoses from most to least likely. For some cases. Fewer than 3 diagnoses will be appropriate. Then, enter the positive or negative findings from the history and physical examination (if present) that support each diagnosis. Lastly, list initial diagnostic studies (if any) you would order for each listed diagnosis (e.g. restricted physical exam maneuvers, laboratory tests, imaging, ECG, etc. Diagnosis #1: Hemorroids HISTORY FINDING(S) PHYSICAL EXAM FINDING(S) - Bloody stool - periumbilical tenderness present - Blood in stool with each bowel movement - bowel sounds present - Drops of blood prior to defecation Diagnosis #2: Colon Cancer HISTORY FINDING(S) - Bloody stool - lost 10 lbs in a week - Diarrhea with rectal spasms Diagnosis #3: Diverticulitis PHYSICAL EXAM FINDING(S) - patient is in no distress - periumbilical tenderness present - bowel sounds present

HISTORY FINDING(S) - Bloody stool - Diarrhea

PHYSICAL EXAM FINDING(S) - periumbilical tenderness - bowel sounds present -

DIAGNOSTIC STUDIES: - Rectal exam, stool for occult blood - Stool for C.difficile toxin - Fecal leukocytes - Colonoscopy - CBC