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Patient History and Symptoms: Describe the patient’s symptoms that led to the suspicion of ulcerative colitis. Include the duration and severity of symptoms like diarrhea, abdominal pain, rectal bleeding, weight loss, and fatigue. Physical Examination: Mention any significant findings during the physical examination. This could include signs of malnutrition, abdominal tenderness, or other relevant findings. Diagnostic Tests: Summarize the results of blood tests, stool tests, imaging studies, and endoscopic procedures. For example, you might mention findings like elevated inflammatory markers in the blood, changes in stool, or visible inflammation in the colon. Diagnosis: State that the patient has been diagnosed with ulcerative colitis based on their symptoms and the results of their diagnostic tests. Treatment Plan: Outline the patient’s treatment plan, including any prescribed medications, recommended lifestyle changes, and plans for follow-up care. what do i write in the finding of this patient?
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