Gastroenterology intake report
Chief complaint
"My bowels haven't been normal for three months."
History of present illness
Change in bowel habit for about 3 months: loose stools 3 to 4 times daily, previously once daily. Intermittent lower abdominal cramping, relieved by defecation. Bright red blood on the toilet paper on two occasions in the past month. About 4 kg unintentional weight loss over 3 months. No dysphagia. No nausea or vomiting.
Relevant history
Hypothyroidism. No prior GI diagnoses reported.
Procedure history
No previous colonoscopy or endoscopy reported.
Medications
- Levothyroxine 75 mcg daily
- Ibuprofen about once a week for back pain
- Allergies: penicillin (rash)
Family history
Father diagnosed with colon cancer at 64.
Flagged for review
Contains only what the patient reported. For clinician review.