BCM Gastroenterology Grand Rounds - History
Previous
Next


Identifiers and Chief Complaint:
68 year-old man with right-sided abdominal pain and bloody diarrhea 
 
History of the Present Illness:
The patient was in his usual state of health until the night prior to admission when he developed sharp, constant, non-radiating right lower quadrant pain with intermittent nausea and vomiting of food particles.  He also noted three episodes of  non-voluminous bloody diarrhea during this period.  He denied hematemesis, melena, fever or chills, tenesmus, dizziness, recent travel, and ill contacts.
Previous Medical Diagnoses, Hospitalizations, and Operations:
Coronary Artery Disease: Myocardial infarction and PTCA (1996)
Paroxysmal Atrial Fibrillation
Hyperlipidemia
Depression
Gastroesophageal Reflux Disease
 
Medications:
Amiodarone
Rabeprazole
Atorvastatin
Digoxin
Sertraline
 
Personal and Social History:
Moderate tobacco use
No excessive alcohol 
No substance abuse
No travel 
 
Family History:
No relevant family history of serious diseases


Previous Next