Patient presents with complaints consistent with proctitis.  Symptoms include rectal bleeding, rectal pain, tenesmus, mucous discharge, and a sensation of incomplete evacuation.  Onset of symptoms was reported as [duration] and is characterized as [acute, chronic, intermittent].  Patient denies fever, chills, nausea, vomiting, or abdominal pain radiating beyond the rectum.  Digital rectal exam revealed [findings e.g., tenderness, erythema, friability, anal fissures, hemorrhoids].  The perianal area appeared [normal, abnormal - specify findings].  Stool consistency is described as [formed, loose, watery, bloody].  Differential diagnosis includes infectious proctitis, radiation proctitis, inflammatory bowel disease (IBD) related proctitis (e.g., ulcerative colitis, Crohn's disease), and ischemic proctitis.  Laboratory tests ordered include stool culture, stool studies for infectious agents (e.g., C. difficile, gonorrhea, chlamydia), and complete blood count (CBC).  Further evaluation may include sigmoidoscopy or colonoscopy depending on the clinical course and laboratory results.  Treatment plan includes [medication, e.g., mesalamine suppositories or enemas, topical corticosteroids, antibiotics if infection is suspected] and patient education on proper hygiene and dietary modifications, such as increasing fiber intake and avoiding irritating foods.  Follow-up appointment scheduled in [duration] to assess response to therapy and adjust treatment plan as needed.  ICD-10 code [K62.89 Other specified diseases of rectum and anus] is considered, pending further diagnostic workup.  Medical necessity for prescribed treatments and diagnostic procedures documented.