Urgent Care, the early signs of colitis May 2007

Below is a dictation of the report from urgent care in May 2007.  This was a year and a half before I was officially diagnosed with UC.  I went into urgent care because I was having poor stools for a long time and some blood on the toilet paper.  I really never really looked too well to see if there was blood in the stools at that time, my guess is there probably was.  I really wonder why I totally forgot to tell the nurse that my uncle has Crohn’s disease.  Maybe had I thought to say that, I would have been about a year and a half further along with getting the ball rolling with my UC.  Instead, my UC found a way to fly under the radar, and eventually landed my right back at the same Urgent Care on September 27th of 2008 in really bad shape.

May 20, 2007

Everything below I retyped from the hard copy medical files I have.

“Adam is an 28 year old male who presents with symptoms of diarrhea which pt describes as soft stools with 2 bouts per day and some blood on the toilet paper but not in the bowel.  patient was in Argentina in November but symptoms began before this.  No other associated symptoms.  Onset 8 months, unchanged since that time.  Patient concerned because symptoms continuing.  other family members affected – no sick contacts.  No history of gastrointestinal disease.  No known risk factors for parasitic or bacterial infection.  Patient denies change in diet or meds.  Has decreaed caffeine consumption.

No past medical history on file.

No past surgical history on file.

No hospital prescriptions on file as of 5/20/07.

Outpatient prescription as of 5/20/2007:
PREDNISONE 10MG PO Tabs, 4 tablets for 2 days, 3 tablets for 2 days, 2 tablets for 2 days, 1 tablet for 2 days.  daily(take with food)

Review of patient’s allergies show no known allergies.

OBJECTIVE:
Blood Pressure 132/82 | Pulse 59   |  Temp 97.4
General appearance: alert, no distress
Hydration: well hydrated
neck: normal, supple and no adenopathy
Lungs: clear to auscultation and percussion
Heart: regular rate and rythm and no murmurs, clicks, rubs or gallops
Abdomen: flat, normal bowel sounds
Tenderness: none
Masses: none
Organomegaly: none
Rectal: stool guaiac negative and normal tone

Assessment:
Chronic Soft Stool for Several Months:  etiology unclear

PLAN:
1) Symptoms are very isolated but will begin initial work-up
CBC: normal
Fecal leukocytes: negative
Stool cx: pending
O&P: pending
Giardia: pending
2) Regular diet
3) Recheck prn persistence, worsening, appearacne of new symptoms, F/U with PMD if symptoms persist for further work up.”




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bacterial infection, bloody toilet paper, diarrhea, disease, gastrointestinal disease, prednisone

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