(Subjective) Chief Complaint: “I still have rectal bleeding”
History of Present Illness: 68 -year old male presents to the office today, s/p hospital discharge on February 13 for blood in stool and diarrhea x 5 days. Patient reports still having blood in the stool. Patient reports that while he was in the hospital an abdominal X ray, 2 units of pack red blood cell, colonoscopy and endoscopy were done, and they were not able to find the source of bleeding. Patient reports seeing the gastroenterologist yesterday and will be following up for further studies with a capsule endoscopy. Pt reports 2 BMs daily, each time with moderate amount of blood on soft stool. Denies V/D/weakness/dizziness pain or body aches. Past Medical History: HLD, CAD, HTN, GERD, Hemorrhoids, Prostate Cancer Past Surgical History: CABG, Pacemaker x 10 years, Radical prostatectomy 3 years ago Current Medications:
OMEPRAZOLE 40 MG 1 delayed release capsule QD for GERD
ASPIR-LOW 81 MG1 delayed-release tablet QD for CAD
COREG 25 MG1 tablet BID for CAD
GEMFIBROZIL 600 MG1 tablet BID for HLD
VITAMIN D3 50,000 INTL UNITS1 capsule QWK Vitamin D Deficiency Social History: former smoker, stopped 15 years ago Allergies: Tylenol-codeine, Symptoms: rash and muscle spasms Family History: father- died due to liver cirrhosis at 85 y/o
mother-deceased- status unknown REVIEW OF SYSTEMS
Constitutional: patient Denies Fatigue, Pain, Fever, Heat intolerance, Weight gain, Weight loss, Night Sweats, Cold intolerance, Poor appetite, Patient acknowledges bleeding
from rectum. Skin: Denies skin, hair changes or rash Eyes: Denies Cataract, Blurry vision, Glaucoma, Double vision, Puffiness of eye lids, Eye pain, Eye redness, Eye discharge, Eye itching, Ears, Nose, Throat: Denies Ear pain, Nasal congestion, Hearing difficulties, Discharge, Hoarseness, Post nasal drip, Dry cough, Productive cough, Eye redness, Lymph node(s) enlargement, Respiratory: Denies Hemoptysis, Wheezing, Snoring, or Cough Cardiovascular: Denies Palpitations, Paroxysmal nocturnal dyspnea, Peripheral edema, Venous thrombosis, Chest pain/discomfort, Dizziness, Diaphoresis, Endocrine: Denies Heat and cold intolerance,
Gastrointestinal: Reports Dark bloody Bowel movement twice daily, Denies Gas and bloating, BM X 2 daily, soft and moderate amount, No constipation, vomiting, dysphagia (difficulty swallowing),
Genitourinary: Reports Change in force of strain when urinating patient has history of Prostate Cancer, Reports some Incontinence or Dribbling, Denies Hematuria, Denies Discharge, Flank pain, , Polyuria,
Immune/Lymph: Denies Lymph node enlargement, Lymph node tenderness,
Musculoskeletal: Denies Back pain, Rash, Redness, Limited range of motion, Joint pain, Arthritis, Cramps, Stiffness, (WNL) Multiple joint pains, Numbness,
Neurology: Denies Balance/gait problems, Headache, Neck stiffness, Seizures, Weakness, Visual changes, Loss of conciousness, Speech impairment, Numbness/Tingling,
Psychiatric: Denies Depression, Memory loss or confusion, Nervousness, anxiety, Insomnia, Crying spells, Auditory hallucinations, History of drug abuse/pain killers,
(Objective) /PHYSICAL EXAM Vital Signs: BP: 107/65 (sitting); Pulse: 60 /min; O2 Sat 98% (on RA) Weight: 165lb; Height: 5 feet 8inches; BMI: 25.1 CBG: 108;
Urinalysis: pH: 6.0 SpecificGravity: 1.020 Protein: Neg Glucose: Neg Ketones: Neg Urobilinogen: 0.2 Blood: Neg Nitrites: Neg Leukocytes: neg Urine Toxicology: Appearance: In no apparent distress Well developed, well nourished, well groomed, not distressed
Skin: No lesion/rash/visible abnormalities, warm to touch, good turgor
Head: Normocephalic and atraumatic
Eyes: EOMI, PERRLA, sclera clear, conjunctiva non-injected
Ears: No redness/swelling. Ear canal is clear with no visible discharge. TM intact.
Nose: Moist mucosa with no septal deviation
Neck: Supple. No LAD/JVD/Thyromegaly. Trachea midline.
Throat: Moist mucosa. No exudates/ulcers/congestion. Tonsils not enlarged. Uvula midline
Respiratory: No hemoptysis, wheezing, snoring, or cough. BL lungs clear CV: RRR, S1+S2+0. No murmur/gallop/rub
Abdomen: Soft, nontender, non-distended. Positive bowel sounds. No rebound/guarding. No organomegaly/mass/ascites.
Back: No redness/swelling. No paraspinal tenderness/spasm. ROM WNL. SLR negative.
Extremities: No erythema/swelling/warmth/tenderness. Sensations intact bilaterally. Power 5/5 bilaterally. DTR 2+. Peripheral pulses 2+
Musculoskeletal: Exam reveals full range of motion, symmetric strength, and normal muscle tone.
Neurological: AAOx3, CN2-12 grossly intact, sensations intact, muscle tone WNL, power 5/5 in all muscle groups, DTR 2+, cerebellar functions intact, gait normal
Psych: Appropriate mood/affect, no delusions, no suicidal/homicidal ideations
Ext. Genitalia: Deferred
Rectal: Deferred (Assessment)/ Test: CBC, CMP, EKG, ANEMIA, Hemoglobin A1c, LIPID PROFILE, PSA, Vitamin D Total Diagnosis: Gastrointestinal Hemorrhage, Unspecified K92.2 GI bleeding is a symptom of a disorder in the digestive tract. The blood often appears in stool or vomit but isn’t always visible, though it may cause the stool to look black or tarry. The level of bleeding can range from mild to severe and can be life threatening Differential Diagnosis: Peptic Ulcer Disease, Gastrointestinal Hemorrhage, Gastric Malignancy Gastric Malignancy: May cause major bleeding, however will typically have more chronic slower bleed. If occult blood or GI bleeding are present malignancy will be considered depending on the presentation. Patient may have a palpable mass, significant weight loss, or no pain with bleeding. Peptic ulcer disease according to Mayo Clinic, are open sores that develop on the inside lining of the upper portion of the small intestine. The most common symptom of a peptic ulcer is stomach pain.
Plan:
Gastrointestinal Hemorrhage, Unspecified: OMEPRAZOLE 40 MG delayed-release capsule QD. Awaiting capsule endoscopy. Discontinue aspirin
capsule QWK
Essential (primary) Hypertension: Continue with same medications. Importance of tight control and being compliant with medicines explained. Decrease sodium intake.
Malignant Neoplasm of Prostate: Continue with lifestyle modifications. Counseling is done in detail.
Referrals: Continue follow up with GI, Urologist, Oncologist Follow up: Follow up office visit in 2 week(s) for lab results If bleeding worsen go to ER
