Identifying Data

Name: Male

Address: NSUH

Date of Birth: 37 y/o

Location: NYHQ

Source of Information: Self

 

Chief Complaint: Rectal bleeding for 1 day 

 

History of Present Illness:

37 y/o male with a PMH of migraines, chronic alcohol abuse, and cirrhosis of liver, last drink June 2019, presenting with rectal bleeding for 1 day. States he has had 7 episodes of bright red blood coming from rectum without passing stool. Patient had a colonoscopy on 1/27/20 s/p polypectomy, and states he felt well after the procedure with regular bowel movements. Admits to nausea, dry heaving, subrapubic tenderness, shortness of breath and lightheadedness. Has a history of internal hemorrhoids with spotting of blood but states the bleeding this time is more significant. Denies any use of anticoagulants, change in weight, fever, weakness, change in appetite, intolerance to specific foods, dysphagia, pyrosis, unusual flatulence or eructations, hematemesis. Denies any urinary frequency or urgency, dysuria, or flank pain.

 

Past Medical History:

Migraine headache  

ETOH use disorder

Cirrhosis  – June 2019 

 

Past Surgical History:

Meniscectomy of left knee – 2008 

Denies any other past injuries or transfusions.

 

Medications:

Thiamine 100 mg PO tab once a day

Gabapentin 100 mg PO tab twice a day 

Lasix 20 mg PO tab once a day 

Vitamin D2 1.25 mg PO tab once a week 

Magnesium gluconate 500 mg PO tab once a day

Folic acid 1 mg PO tab once a day 

Allergies:

NKA

Denies other drug, environmental or food allergies.

 

Family History:

Father – COPD

Sister – multiple sclerosis 

 

Social History:

ETOH use disorder – last drink June 2019

 

Review of Systems:

General – Denies recent weight loss or gain, loss of appetite, generalized weakness/fatigue, fever or chills, or night sweats.

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Admits to migraine headaches. Denies vertigo or head trauma.

Eyes – Denies pruritus, lacrimation, corrective lenses, photophobia or other visual disturbances.

Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat – Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes or use dentures. Last dental exam 2019, normal.

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion

Pulmonary system –Admits to dyspnea and dyspnea on exertion, Denies cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).

Cardiovascular system – Denies chest pain, irregular heartbeat, palpitations, edema/swelling of ankles or feet, syncope or known heart murmur

Gastrointestinal system – see HPI

Genitourinary system – See HPI 

Nervous – Denies seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status / memory, or weakness.

Musculoskeletal system – Denies muscle/joint pain, deformity or swelling, redness or arthritis.

Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.

Hematological system – Denies anemia, easy bruising, lymph node enlargement, blood transfusions, or history of DVT/PE.

Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter

Psychiatric – Denies history of depression or anxiety. Denies OCD or other psychiatric disorders. 

 

Physical Exam

Vitals 

Pulse:71, regular 

BP: 105/55

RR: 18, unlabored 

Temperature: 98.4 F oral

Pulse ox: 98% on room air 

BMI: 22.4

 

General – AOX3, in no acute distress, good hygiene, appears stated age

HEENT – no masses, lesions, deformities. PERRL, EOM. No papilledema, nasal discharge, exudates, lymphadenopathy, erythema. Trachea midline

Skin – warm and dry, good turgor. No rashes, bruises, or masses.  

Cardiac – regular rate and rhythm. No murmurs/rubs/gallops. No JVD or carotid bruits

Lungs – clear to auscultation bilaterally. No use of accessory muscles. No wheezes/ rales/ rhonchi

Abdominal – Bowel sounds present in all quadrants. Abdomen soft. Non tender and non distended. No aortic/ renal bruits. No organomegaly.

Musculoskeletal – no soft tissue swelling, erythema, ecchymosis, atrophy or deformities in bilateral upper and lower extremities. FROM in upper and lower extremities b/l. No spinal deformities. 

Peripheral Vascular – Color and temperature wnl. Pulses 2+ bilaterally in upper and lower extremities b/l. No cyanosis, clubbing or edema. No palpable varicose veins.

Neurological – AOx3. Memory and attention intact. Receptive and expressive abilities intact. No dysarthria, dystonia or aphasia. 

CN: I – intact

II – VA20/20 bilaterally, visual fields full, pupillary reaction to light OU

III, IV, VI – PERRLA, EOMI, no nystagmus

V – facial sensation intact, facial muscles intact *did not test corneal reflex*

VII – facial movements symmetrical without weakness

VIII – hearing intact to whispered voice b/l. *did not perform Weber or Rinne*

IX, X, XII – swallowing intact *did not test gag reflex*, uvula elevates midline. Tongue movement intact

XI – shoulder shrug intact. Sternocleidomastoid and trapezius muscles intact. 

Motor/Cerebellar – Full active/passive ROM of all extremities without rigidity or spasticity. Muscle tone and bulk wnl. No atrophy, tremors, tics or fasciculations. Strength equal and appropriate for age b/l. No pronator drift. Gait normal with no ataxia. Balance intact. Point to point intact b/l.

Sensory – intact to light touch, sharp/dull, point localization, extinction b/l. *Did not test vibrations or reflexes*

Meningeal signs – no nuchal rigidity. Brudzinski’s and Kernig’s sign negative  

 

Labs/Diagnostics

CMP

139| 105 | 15    ( 147 (H)

4.5 | 21 (L)   | 0.74

 

CBC

15.22> 9.2< 168

           28.3

 

Albumin 3.6

Bilirubin 1.5 (H)

AST 51 (H)

ALT 27

Alk phosphatase 170 (H)

 

PT – 22.6

PTT – 31.1

INR – 1.94

 

Occult blood – positive 

 

CXR – wnl

 

ECG – normal sinus rhythm 

 

Colonoscopy report – 

Transverse colon polyp, biopsy 

• Tubular adenoma 
• Cauterized base of stalk is negative for dysplasia  

Ascending colon polyp, biopsy 

• Tubular adenoma 

• Cauterized base of stalk is negative for dysplasia 

 

Assessment and Plan

37 y/o male with history of migraines, ETOH use disorder, cirrhosis, recent colonoscopy on 1/27 s/p polypectomy presenting with hematochezia for 1 day.

 

DDX:

1. Anal fissure 
2. Hemorrhoids 
3. Ulcerative colitis 
4. Crohn’s disease 
5. Diverticulosis 
6. Colon cancer 

 

Plan:

1. Acute blood loss anemia – trend H/H, PRBC as needed, colonoscopy
2. GI bleed – same as above
3. Alcoholic cirrhosis of liver without ascites – hold lasix in setting of GI bleed, continue with folic acid and thiamine