1 Health Assessment of a Patient with Rectal Bleeding Patient Initials: MM
Age: 62
Gender: M
SUBJECTIVE DATA: Chief Complaint (CC): Rectal bleeding History of Present Illness (HPI): MM is a 62-year-old male who works as a construction worker. He is complaining of experiencing rectal bleeding. The bleeding has lasted for over month. He has noted a small amount of blood in his stool after every bowel movement. He also experiences occasional rectal itching and pain. He denies any noticeable sores in his rectal area. Medications: None Allergies: None Past medical history: None Past surgical history: None Sexual/ reproductive history: Heterosexual, sexually inactive Personal/ social history: He works for a construction company doing manual works. He does not use any illicit drugs, does not drink or smoke.
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2 Immunization history: None Significant family history: He has no family history of colorectal cancer. Lifestyle: He is a construction worker Review of Systems:
General: Has no fever or chills, reports rectal bleeding
HEENT: He has noted small amounts of blood after bowel movements. The condition has lasted for about a month.
Neck: No pain or injury
Respiratory: Normal
CV: Normal, has never had cardiac problems
GI: Denies abdominal pain, has no nausea or vomiting. He is experiencing rectal bleeding, has no visible sores on his rectal area.
GU: Has no abnormal urinary frequency or dysuria
MS: Little pain in hand muscles, maybe due to heavy work
Psych: No history of anxiety, depression, disturbance or mental health history.
Neuro: Intact
Integument/Heme/Lymph: Intact.
Endocrine: No endocrine symptoms or hormone therapies.
Allergic/Immunologic: None.
OBJECTIVE DATA Physical Exam:
3
Vital signs: B/P 121 /58, left arm, sitting, regular cuff; P 65 and regular; T 98.0 orally; RR: 16 non-labored; Wt: 72 kg; Ht; 1.5m BMI: 24
General: A&O x3. Within normal limit.
Neck: within normal limit.
Chest/Lungs: Clear lung sound. Within normal limit
Heart/Peripheral Vascular: within normal limit.
ABD: within normal limit.
Musculoskeletal: within normal limit
Neuro: CN intact
Skin/Lymph Nodes: Palpable nodes
ASSESSMENT: Lab Tests and Results: None Diagnostics: 1. Rectal examination 2. Colonoscopy 3. Fecal occult blood 4. Sigmoidoscopy. The use of a sigmoidoscope camera to check for hemorrhoids. Differential Diagnosis: 1. Hemorrhoids. Presents with itching, irritation, and pain around the rectal area. It is associated with consistent heavy lifting. It can also be passed from parents to children although the patient has no family history of any hemorrhoids (Peery et al., 2015). 2. Anal fissure. It is an ulcer or a tear on the anal canal. It causes a sharp pain when passing stool which is accompanied by blood in stool (Mapel, Schum, & Von Worley, 2014).
4 3. Colon cancer and colon polyps. These are growths found in the colorectal area and can be non-cancerous (polyps). Polyps can develop into colon cancer. This condition is common in families with a history of the disease (Adrouny, 2002). 4. Angiodysplasia. This condition is common among the elderly and is characterized by swelling of blood vessels in the colon. Stool passed has bright red or black blood in them. However, it is not associated with pain (Shimizu, Koike, Nomura, & Ooe, 2016). 5. Colitis. This is the inflammation of the colon or the rectum and can cause rectal bleeding. An ulcer may develop on the inflamed part; hence the rectal bleeding. It can cause inability to defecate (Pilarczyk-Zurek, Strus, Adamski, & Heczko, 2016).
5 References Adrouny, A. R. (2002). Understanding colon cancer. Jackson, MS: University Press of Mississippi. Mapel, D. W., Schum, M., & Von Worley, A. (2014). The epidemiology and treatment of anal fissures in a population-based cohort. BMC Gastroenterology, 14(1), 129-135. doi:10.1186/1471-230X-14-129 Peery, A. F., Sandler, R. S., Galanko, J. A., Bresalier, R. S., Figueiredo, J. C., Ahnen, D. J., & ... Baron, J. A. (2015). Risk factors for hemorrhoids on screening colonoscopy. Plos ONE, 10(9), 1-9. doi:10.1371/journal.pone.0139100 Pilarczyk-Zurek, M., Strus, M., Adamski, P., & Heczko, P. B. (2016). The dual role of Escherichia coli in the course of ulcerative colitis. BMC Gastroenterology, 161-11. doi:10.1186/s12876-016-0540-2 Shimizu, T., Koike, D., Nomura, Y., & Ooe, K. (2016). Colonic angiodysplasia with a huge submucosal hematoma in the sigmoid Colon. Case Reports in Surgery, 20163457367. doi:10.1155/2016/3457367