# Medical History Report – Thandiwe Mokoena

**Age:** 28  
**Sex:** Female  
**Ethnicity:** Black South African  
**Occupation:** Primary School Teacher  
**Location:** Cape Town, South Africa  

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## 🩺 Chief Complaint

Persistent abdominal pain and diarrhea over the past three months.

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## 📖 History of Present Illness

Thandiwe reports a three-month history of intermittent crampy abdominal pain, predominantly in the right lower quadrant. She experiences 4–6 loose, non-bloody stools daily, often accompanied by urgency. Over the past month, she has noticed increased fatigue and an unintended weight loss of approximately 5 kg. She denies any recent travel, antibiotic use, or dietary changes.

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## 🧾 Past Medical History

- No prior chronic illnesses  
- Appendectomy at age 12  
- No known drug allergies  

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## 👨‍👩‍👧 Family History

- **Mother:** Hypertension  
- **Father:** Type 2 Diabetes Mellitus  
- No family history of gastrointestinal diseases  

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## 🌍 Social History

- Non-smoker  
- Occasional alcohol consumption  
- Engages in regular physical activity  

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## ✅ Review of Systems

- **General:** Reports fatigue and weight loss  
- **Gastrointestinal:** Abdominal pain, diarrhea, occasional nausea  
- **Other systems:** No fevers, skin rashes, or joint pains reported  

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## 🧑‍⚕️ Physical Examination

- **Vital Signs:**
  - BP: 118/76 mmHg
  - HR: 82 bpm
  - Temp: 37.2°C
  - RR: 16 breaths/min
- **General:** Alert and oriented; appears mildly fatigued  
- **Abdomen:** Soft with tenderness in the right lower quadrant; no rebound tenderness or guarding; no palpable masses  
- **Perianal Examination:** Normal; no fissures or fistulas observed  

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## 🧪 Laboratory Investigations

- **CBC:**
  - Hemoglobin: 10.5 g/dL (mild anemia)
  - WBC: 9.8 x10⁹/L  
- **CRP:** Elevated at 25 mg/L  
- **ESR:** Elevated at 40 mm/hr  
- **Stool Studies:** Negative for pathogens; fecal calprotectin elevated  

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## 🖥 Imaging and Endoscopy

- **Colonoscopy:** Patchy areas of inflammation with ulcerations in the terminal ileum; cobblestone appearance noted  
