Patient Information:
Initials, Age, Sex, Race AB, 62 year old White Male
S.
CC The patient complains of rectal bleeding after bowel
movement for over 1 month. He also complains of itching and
pain.
HPI:
Location: rectum
Onset: 1 mth ago
Character: burning
Associated signs
and symptoms:
itching and bleeding
Timing: frequently
but most often after
BM
Exacerbating/
relieving factors:
preparation H
cream or wipes
after BM
Severity: 4/10 pain
scale
Current Medications: ASA 81 mg QD, Coreg 3.125 Po BID,
Lisinopril 5 mg PO QD, Simvastatin 40 mg PO HS, Norco 5/325
1-2 tabs Q4HR prn back pain, preparation H cream and wipes
as needed, Tamsulosin 4 mg QD,
, Allergies: NKDA
PMHx: All immunizations current, flu vaccination 10/1/17,
tetanus vaccine 1/1/16, CAD, MI 2/5/16, drug eluding stent
placed 2/5/16, Colonoscopy- 6/5/15-no polyps, Degenerative
Disk Disease
Soc Hx: Patient is a construction worker foreman, denies illicit
drug use, drinks up to 3 alcoholic beverages a week, used
chewing tobacco for 10 years quit in 2016, smoked cigarettes
1PPD for 30 years quit in 2016, Lives with wife, 3 grown
children and 6 grandchildren,
Fam Hx: Father died at 68 from MI, Mother living with DM,
and Stroke, unknown history for grandparents. 1 Sister had
CAD and breast cancer, Children and grandchildren are
healthy..
ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or
yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing,
congestion, runny nose or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest
discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or
diarrhea. No abdominal pain or blood. Itching, pain and small
amount of bleeding after BM. Constipation occasionally from
opioid use.
GENITOURINARY: no burning during urination. Urinary
frequency at night, better since starting tamsulosin.
Initials, Age, Sex, Race AB, 62 year old White Male
S.
CC The patient complains of rectal bleeding after bowel
movement for over 1 month. He also complains of itching and
pain.
HPI:
Location: rectum
Onset: 1 mth ago
Character: burning
Associated signs
and symptoms:
itching and bleeding
Timing: frequently
but most often after
BM
Exacerbating/
relieving factors:
preparation H
cream or wipes
after BM
Severity: 4/10 pain
scale
Current Medications: ASA 81 mg QD, Coreg 3.125 Po BID,
Lisinopril 5 mg PO QD, Simvastatin 40 mg PO HS, Norco 5/325
1-2 tabs Q4HR prn back pain, preparation H cream and wipes
as needed, Tamsulosin 4 mg QD,
, Allergies: NKDA
PMHx: All immunizations current, flu vaccination 10/1/17,
tetanus vaccine 1/1/16, CAD, MI 2/5/16, drug eluding stent
placed 2/5/16, Colonoscopy- 6/5/15-no polyps, Degenerative
Disk Disease
Soc Hx: Patient is a construction worker foreman, denies illicit
drug use, drinks up to 3 alcoholic beverages a week, used
chewing tobacco for 10 years quit in 2016, smoked cigarettes
1PPD for 30 years quit in 2016, Lives with wife, 3 grown
children and 6 grandchildren,
Fam Hx: Father died at 68 from MI, Mother living with DM,
and Stroke, unknown history for grandparents. 1 Sister had
CAD and breast cancer, Children and grandchildren are
healthy..
ROS:
GENERAL: No weight loss, fever, chills, weakness or fatigue.
HEENT: Eyes: No visual loss, blurred vision, double vision or
yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing,
congestion, runny nose or sore throat.
SKIN: No rash or itching.
CARDIOVASCULAR: No chest pain, chest pressure or chest
discomfort. No palpitations or edema.
RESPIRATORY: No shortness of breath, cough or sputum.
GASTROINTESTINAL: No anorexia, nausea, vomiting or
diarrhea. No abdominal pain or blood. Itching, pain and small
amount of bleeding after BM. Constipation occasionally from
opioid use.
GENITOURINARY: no burning during urination. Urinary
frequency at night, better since starting tamsulosin.
