A -Year-Old Gentleman/Lady with History Of

[Present illness]

A -year-old gentleman/lady with history of

presented with bloody stool for one day. He/She was in his/her usual health until approximately 1 day before admission, when he/she reportedly began to feel unwell, with bloody stool and abdominaldiscomfort. He/She did not have the similar symptom before. He/She denied abdominal cramping pain, nausea, vomiting, change of bowel habit, or tenesmus. He/She did not have fever, night seating, weight loss, general malaise, or appetite either. He/She did not have the surgical or radiationhistory in the gastrointestinal system before. He/She had no history of cirrhosis or chronic kidney diseasefor a long time with baseline AST/ALT/BUN/Cre level of.According to his/her statement, he/she did not have alcohol addiction and non-steroidal anti-inflammatory drug for any purpose. Neither antiplatelet nor anticoagulant was taken. He/She did not experience palpitation, thirsty, dizziness, or syncope. The symptoms and signs persisted despite the discontinuation of the meal. Due to the persisted symptoms and signs, he/she was brought to our emergency department (ED) for management. The vital sign and blood pressure upon arrival to our ED was // and /mmHg, respectively. The oxygen saturation was % under the ambient air. However, oxygen mask at a rate of 6 liters per minute was supplied for fear of possible hypoxemia. The laboratory report revealed WBC/Hb/PLT of, BUN/Cre of, Na/K of, ALT/CRP of. The arterial blood gas revealed ///. The urinalysis revealed hematuria, pyuria, and bacteriuria. The chest X-ray revealed. On digital examination, he did not feel pain or discomfort. There was no evidence of hemorrhoid, anal fissure, or other protruding mass. Under the tentative diagnosis of, he/she was admitted to ward for further management on.

[Past history]

1. Medical history: Nil.

2. Surgical history: Nil.

3. Allergy history

Medication allergy: Nil.

Medication ADR: Nil.

中草藥: Nil.

保健食品: Nil.

4. Current medication

Nil.

5. Family history

No other systemic disease among other family members.

6. Travel/Occupation/Cluster/Contact history

Nil/Nil/Nil/Nil

7. Social history

Alcohol (-), Betel nut (-), Cigarette (-)

[Neurological examination]

1. Consciousness: clear and alert, E4M6V5

2. Muscle power: 5 of 5 in both upper and lower extremities

3. Gait: normal

[Physical examination]

1. General: ill-looking

2. Consciousness: clear and alert, E4V5M6

3. Head-Eye-ENT

The skull is normocephalic/atraumatic. The conjunctiva was anicteric and not pale. The pupils are 4 mm constricting to 2 mm, equally round and reactive to light and accommodations. The extraocular movement was intact. The nasal mucosa was pink without septum deviation. No sinus tenderness. The oral mucosa was pink, wet and no ulcer. The dentition was good. Neither exudates nor enlarged tonsil was found in pharynx.

4. Neck

The trachea was in midline. The neck was supple without stiffness. Neither goiter nor lymphadenopathy was noted. No jugular vein engorgement.

5. Chest

Thorax is symmetric with good expansion. Tactile fremitus was detected bilaterally. Lungs were resonant. Breath sounds vesicular; no rales, wheezes, or rhonchi.

6. Heart

Carotid upstrokes are brisk without bruits. The point of maximal impulse is tapping, 7 cm lateral to the midsternal line in the 5th intercostal space. Good S1 and S2. No murmurs or extra sounds.

7. Abdomen/back

Abdomen is protuberant with normoactive bowel sounds. It is soft and nontender; no masses or hepatosplenomegaly. Liver span is 8 cm in the right midclavicular line. Neither shifting dullness nor rebound tenderness was noted. Spleen and kidneys are not felt. No costovertebral angle tenderness.

8. Skin

Color good. Skin warm and moist. Nails without clubbing or cyanosis. No suspicious nevi. No rash, petechiae, or ecchymoses.

9. Extremities

Extremities are warm and without edema. No varicosities or stasis changes. Calves are supple and nontender. No femoral or abdominal bruits. Brachial, radial, femoral, and dorsalis pedis pulses are 2+ and symmetric.

[Review of system] (■ represent positive finding)

1. Systemic: weight loss □, easy-fatigability □, night sweats □

2. Skin: petechiae □, purpurae □, skin rash □, itching □

3. HEENT: headache □, dizziness □, blurred vision □, strabismus □, ocular pain □, otalgia □, otorrhea □, hearing impairment □, tinnitus □, vertigo □, nasal stuffiness □, nasal discharge □, epistaxis □, gum bleeding □, sore throat □, oral ulcer □

4. Cardiovascular: exertional chest tightness □, nocturnal dyspnea □, orthopnea □, syncope □, palpitation □, intermittent claudication □

5. Respiratory: exertional dyspnea□, productive cough □, chest pain □, hemoptysis □, pleuritic chest pain □, hemoptysis □

6. Gastrointestinal: anorexia □, nausea □, vomiting □, dysphagia □, heartburn □, acid regurgitation □, abdominal fullness □, hunger pain □, midnight pain □, constipation □, diarrhea □, melena □, change of bowel habit □, small caliber of stool □, tenesmus □, flatulence □, abdominal pain □

7. Urogenital: flank pain □, hematuria □, urinary frequency □, urgency □, dysuria □, hesitancy □, small stream of urine □, impotence □, nocturia □, polyuria □, oliguria □

8. Musculoskeletal: bone pain □, arthralgia □, myalgia □, weakness □, back pain □

9. Metabolic: heat intolerance □, cold intolerance □, thirsty □

10. Nervous: numbness □, paresis/plegia □