DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Rectal bleeding.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who comes into the emergency department reporting that she was having a bowel movement and she noted significant amount of rectal bleeding today. The patient has had it intermittently for the past week. The patient has had some pain in the abdomen as well, which is mild, 2-3/10, not crampy. It comes and goes spontaneously. The patient has no other complaints. No fever or chills. No cough or phlegm. No urinary symptoms. No neurologic complaints.
PAST MEDICAL HISTORY: History of rheumatoid arthritis and osteoporosis.
PAST SURGICAL HISTORY: Tonsillectomy and adenoidectomy, hysterectomy, and the patient has had eye surgery, cataract surgery, and sinus surgery.
MEDICATIONS: None.
ALLERGIES: Listed in the chart.
SOCIAL HISTORY: The patient does not smoke cigarettes. No use of alcohol. No use of drugs. The patient is divorced.
FAMILY HISTORY: Father died from complications of CHF. Mother died from complication of coronary artery disease.
REVIEW OF SYSTEMS: All other systems are reviewed and are negative, except for symptoms reported in the HPI.
PHYSICAL EXAMINATION:
GENERAL APPEARANCE: The patient is alert and oriented. She is not in apparent distress. Anicteric, acyanotic, well developed, and well nourished.
VITAL SIGNS: Blood pressure 164/66, pulse 80, respiratory rate 20, temperature 97.8, and pulse oximetry 98% on room air.
HEENT: Head: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light and accommodation. No drainage from ears or nose. Oropharynx is clear.
NECK: Supple.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm. S1, S2. No murmurs or gallops.
ABDOMEN: Soft and benign. No rebound or guarding.
EXTREMITIES: Full range of motion. No clubbing, cyanosis or edema.
NEUROLOGIC: The patient moves all extremities freely. Cranial nerves are grossly intact.
LABORATORY DATA: The patient had guaiac test that was positive with no bleeding noted to be present. She has brown stools. NG lavage was done. The patient had a negative lavage. CPK 20, troponin 0.01. LDL 106. White count 4.3, H and H 11.2 and 33.2, and platelets 196 with 57 neutrophils, 26 lymphocytes, 11 monocytes, 4 eosinophils, 1 basophil. ALT 34, alkaline phosphatase 108, AST 20, total bilirubin 0.4. Sodium 138, potassium 3.6, chloride 96, CO2 of 30, glucose 100. BUN and creatinine 22 and 0.5, calcium 9.4. Total protein 7.8, albumin 3.8, globulin 4, PT 13.2, INR 1.03, PTT 27.6, magnesium 2.3. UA is negative.
DIAGNOSTIC DATA: The patient had diagnostic studies done in the emergency department. She had an EKG that showed normal sinus rhythm, rate of 66, QRS duration of 86, axis 75. No ST segment elevation or depression. No T-wave inversion. Chest x-ray showed normal bony structures. No widening of the mediastinum. No cardiomegaly. No vascular congestion. She has hyperexpansion. She is noted to have barrel chest.
EMERGENCY DEPARTMENT COURSE: The patient will be discharged to home. The patient was instructed to follow up with her primary care provider.
ASSESSMENT: The patient is a (XX)-year-old female with rectal bleed, stable.
PLAN:
1. The patient will be discharged to home.
2. Follow up with her primary care doctor.
