Gastroenterology case study

HISTORY AND PHYSICAL EXAMINATION

CHIEF COMPLAINT

A 55-year-old white female patient who has internal/external hemorrhoids with considerable tissue degeneration at certain gangrenous-appearing sites.  The patient was seen by me the day before yesterday, and then her insurance required a second opinion confirming the pathology.  The patient does have very sore, very painful internal/external hemorrhoids with spots of gangrene.  The patient needs a bowel prep throughout the day today, clear liquids and laxatives, and enemas in the morning, and I plan to schedule her then, in the morning, which is Saturday morning, for a hemorrhoidectomy on an emergency basis.

          

PAST MEDICAL HISTORY

The patient’s past medical history indicates that she has had hemorrhoids for 26 years, but in the past 30 days they got bad and kept getting worse.  The patient is very sore, walks with difficulty, and needs attention to this pathology.

ALLERGIES

SHE IS ALLERGIC TO ASPIRIN, PENICILLIN, AND CODEINE.

MEDICATIONS

She is on Slow-K 1 daily, Saluron 50 mg daily, and Tenormin
1 daily.  The Tenormin is a 50 mg tablet also.

PHYSICAL EXAMINATION

GENERAL:  This lady is rather uncomfortable.

RECTAL:  The patient, on her right side of her anus, has thrombosed, gangrenous internal/external hemorrhoids.  She also has a bunch of skin tags around the rectum from previous problems.  Digital examination is negative beyond the hemorrhoid point.  Proctoscopy done is helpful to identify the pathology.

CONCLUSION AND DISCUSSION

I have discussed with this lady that she needs her surgery.  She has been seen in second opinion; her insurance requires that.  The patient has internal/external hemorrhoids with thrombosis and gangrene.  I am starting her on clear liquids at this moment, laxatives this afternoon, enemas till clear in the morning, and do her at 9 o’clock in the morning.

FOOTNOTE

Lines 9, 10 (Page 1).  The physician dictated with
gangrenous-appearing sites at certain gangrenous-occurring sites.  This was edited to at certain gangrenous-appearing sites.

Line 17 (Page 1).  To correct the redundancy, based on an emergency basis was edited to on an emergency basis.

Line 19 (Page 1).  The heading Past Medical History was added for clarity.

Line 38 (Page 1).  The slang term procto was expanded to proctoscopy.