Case Report: 2

Chief Complaint (CC):

Patient presented to the clinic with complaints of mucoid diarrhea for the past three weeks.

History of Present Illness (HPI):

68-year-old M, reports experiencing frequent episodes of mucoid diarrhea, which are often
accompanied by urgency and tenesmus. He denies any associated abdominal pain, blood in the stool,
fever, or weight loss.

Past Medical History (PMH):

Patient has a history of hypertension, which is well-controlled with medication. He was diagnosed with
prostate cancer one year ago and underwent radiation therapy as primary treatment, six months ago.

Family History (FH):

There is no significant family history of gastrointestinal conditions or malignancies.

Social History (SH):

Patient is a non-smoker and consumes alcohol occasionally. He is retired and leads a sedentary lifestyle.

Physical Examination:

-Vital Signs:

- Blood Pressure: 140/85 mmHg

- Heart Rate: 78 bpm

- Respiratory Rate: 16/min

- Temperature: 37.0°C (98.6°F)

- Oxygen Saturation: 98% on room air

General: Alert and oriented, in no acute distress

Abdomen: Soft and non-tender, no palpable masses

Rectal Examination: No evidence of hemorrhoids or fissures. The rectal mucosa appears normal, and
there is no palpable mass. Minimal stool in the rectal vault.
**Laboratory Investigations:**

- Complete Blood Count (CBC): Within normal limits

- Basic Metabolic Panel (BMP): Within normal limits

- Stool Culture: Negative for pathogens

- Stool for Clostridioides difficile Toxin: Negative

**Differential Diagnosis:**

1. Radiation Proctitis: mucoid diarrhea with a history of pelvic radiation.

2. Inflammatory Bowel Disease (IBD): mucoid diarrhea,

Management

1. Colonoscopy

2.. Rectal corticosteroids or mesalamine