HISTORY OF PRESENT ILLNESS: This (XX)-year-old Hispanic lady was referred for evaluation of hematochezia. For the past three months, the patient has noted rectal bleeding. This blood tends to be fresh but can be mixed with the stool. There has been no frank abdominal pain, and she denies any subtle change in her bowel habit; although, she may have a tendency for constipation. She typically would have a bowel movement every other day. There has been no stool urgency, rare episodes of incomplete stool evacuation, no tenesmus. She does have a history of hemorrhoids, remote. The patient has undergone a colonoscopy by us, at which time a colonic polyp was removed. The patient denies any loss of appetite or loss of weight. There is no known family history of colonic neoplasm.
PAST MEDICAL HISTORY: The patient has had LASIK surgery to the eye. She has had a tummy tuck. She is known to have degenerative joint disease and osteopenia. No TB, diabetes.
ALLERGIES: No known drug allergies.
CURRENT MEDICATIONS:
1. Tums calcium two daily.
2. Vitamin D3, 2000 units daily.
3. Aspirin 81 mg daily.
4. Cod liver oil daily.
5. Celebrex 200 mg daily.
REVIEW OF SYSTEMS:
CARDIOVASCULAR: No angina, PND, orthopnea, claudication.
RESPIRATORY: No cough, sputum, hemoptysis, wheezing.
GENITOURINARY: She notes rare episodes of urinary stress incontinence.
MUSCULOSKELETAL: No acute arthritis. She has had some discomfort in her right knee and left shoulder.
CENTRAL NERVOUS SYSTEM: No headache, diplopia, seizures or focal weakness.
SOCIAL HISTORY: The patient is a nonsmoker, social drinker. She has been under some stress. She walks three times per week. Her diet is well balanced.
FAMILY HISTORY: Unremarkable for colonic neoplasm.
PHYSICAL EXAMINATION:
GENERAL: The patient is in no acute distress. She appears much younger than stated age.
VITAL SIGNS: Weight 106 pounds; pulse 72 per minute, regular; BP 142/76 in the right arm; respirations 18 per minute.
HEENT: No pallor, icterus, lymphadenopathy. Normocephalic. Pupils react to direct light. Throat is clear. Tongue is well papillated.
NECK: Thyroid without masses. No carotid bruits.
HEART: Normal first and second heart sounds. No murmurs, clicks, S3 or rubs.
RESPIRATORY: Trachea central. No dullness. Good air entry without rales or rhonchi.
ABDOMEN: Soft. No tenderness, guarding, hepatosplenomegaly, masses or ascites. Bowel sounds are normal. Inguinal hernial sites intact. Scar of tummy tuck noted, horizontal incision in the abdomen.
RECTAL: Slight erythema is noted around the anal verge. One perianal skin tag is noted. No rectal masses palpable. Burgundy stool, strongly Hemoccult positive, is noted on finger cot.
NEUROLOGIC: Cranial nerves II through XII intact. Reflexes present and equal. Coordination intact.
MUSCULOSKELETAL: Slight limited range of rotatory movements of the neck. Good range of motion of the hips. Good foot pulses. No clubbing or cyanosis.
IMPRESSION:
1. Chronic hematochezia with likely causes including:
a. Rule out bleeding diverticulosis coli.
b. Rule out bleeding colonic neoplasm.
c. Doubt bleeding internal hemorrhoid.
d. Doubt inflammatory bowel disease.
2. History of colonic polyp.
3. Tendency to constipation, functional, possibly related to chronic hematochezia.
4. Suspect degenerative joint disease, right knee, mild severity.
PLAN:
1. Reassurance, explanation.
2. To check CBC, sed rate, comprehensive metabolic panel, and TSH.
3. To proceed with colonoscopy, possible biopsy, possible polypectomy.
4. To review previous records.
5. To discontinue aspirin at this time.
6. Probiotic Align one daily.
7. Further treatment will depend on findings of above studies. Close followup.
