HX & PE

1. CHIEF COMPLAINT
Hematochezia

2. History of Present Illness

3. History of Present Illness

4. 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

5. Personal and Social History
 Retired cook
 Lives with his wife
 22 years smoker: 66 pack years
 Completed 2 doses of ____ vaccine. No booster

6. 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

7. Physical examination
V/S:
 BP: 130/80 mmhg
 HR: 86 bpm
 RR: 19 cpm
 O2Sat: 99% room air
General: patient seen and examined awake, afebrile, coherent not in
respiratory distress with the following vital signs:
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

8. 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

9. THANKS