Started a month ago with every bowel movement. He has bright red blood mixed with brown stool, without any mucous. He has been constipated for long time for which he used to take laxatives and stopped taking them recently since they weren't helping him. He says his condition is getting worse. 10 lb weight loss and nl appetite
another way to write the same thing "Recurrent episodes of stool, brown in color, (consistency?), mixed with bright red blood occurring (how frequently?) times a day for a month, gradually worsening?, associated with constipation and 10 lbs weight loss, but without any mucus or (
pain during defecation?)."
Constipation and weight loss over what duration?
What question should you have asked to include anal fissure in your DD specifically?
He says his condition is getting worse
In what way?
PMH/PSH- Hemorroids resected 4 years ago and Bronchitis
Bronchitis duration?
Smoking history? and what about
alcohol history in this patient?
No mention of PFH with father having Colon Ca at age 55 in the history, but you've included it as a supporting finding in the differential.
Abd- Soft, NT/ND, +BS bilateral 4x, no rebound tenderness or gaurding, -Murphy
Organomegaly findings? (any need to check for hepatomegaly?) Relevance of Murphy's sign to this case?
Investigations:
Better to write "Digital rectal exam". "Rectal exam" could mean any method of exam.
Why not include the sub-investigations under a major title? For eg Stool microscopy (FOBT, etc.)
My impressions:
1. Room for improvement regarding language and technical quality. Physicians check your notes.
3. In ROS, ask questions that will specifically help you to rule in/rule out major differentials or assess for potential complications. Same applies to examinations.
