Sample Write-Up #2

Grade:14/15

Comments: Nice job, good discussion. Fairly straight forward. Left off health maintenance.

Patient Name: D.R.

DOB: 8/16/1956

Source: Patient who is very reliable. Additional information was gathered from old record’s in the VA database as the patient receives his medical care through the VA Syracuse.

CC: “I’ve been having bloody bowel movements.”

HPI: The patient is a 48-year-old Caucasian male with a past medical history significant for dyslipidemia and hypertension who comes in complaining of a one day history of rectal bleeding. Tuesday afternoon he felt the need to have a bowel movement and afterward noticed a moderate amount of bright red blood on both the tissue paper as well as in the toilet bowl staining the toilet water bright red. He describes a few small clots of blood in the toilet bowl as well. At 2:00 AM on Wednesday morning he was awoken from sleep with the feeling of pressure in his rectum as though he needed to have a bowel movement. He passed no stool but instead a large amount of bright red blood as well as large clots that were present in the toilet water with subsequent relief of the rectal pressure. At this time he became concerned and went to the Syracuse VA ER where he subsequently had two similar episodes of rectal pressure and relief with the passage of moderate amounts of bright red blood and clots. He is unaware of any aggravating or alleviating factors. D.R. has not had any similar episodes of rectal bleeding prior to this. He denies associated fever, chills, lethargy, nausea, vomiting, diarrhea, dizziness, abdominal pain, cramping, chest pain, or headaches at any time. He also denies any hematemesis, hemoptysis, recent melena, rectal pain, recent rectal trauma, foreign body insertion or anal intercourse. He is not aware of having any hemorroids. Although he does have chronic back pain he denies chronic NSAID use only using Tylenol one time a month. He does not take anticoagulants for any medical conditions and although he has a past history of heavy alcohol use he has not used alcohol in 20 years.

The patient states that he has been consistent with trying to lose weight and has been successful in losing approximately 20lbs over the past four months with the purpose of getting reregistered for the army reserves. During this time the patient admitted to eating much less than usual with his diet consisting mostly of macaroni and cheese for both lunch and dinner. He does not eat breakfast and restrains himself from snacking. The patient reports he subsequently has had a decrease in bowel movements. He now has a bowel movement every other day where prior to his diet he was having bowel movements at least once a day and sometimes twice a day. He denies that he strains to have bowel movement or any changes in the consistency of his bowel movement as well as any changes in the color or smell. He reports his last normal bowel movement to have been yesterday morning before the onset of the rectal bleeding. He has never had a colonoscopy.

The patient is afraid this is the result of eating at a Chinese restaurant with some friends two days ago. However, he denies any symptoms since eating there besides this recent onset of rectal bleeding and denies any of his friends being ill. He also denies recent sick contacts, recent travel, family history of IBD, colon cancer or coagulation disorders.

PMH:

Hypertension

Diagnosed - March 2005
Symptoms- None
Treatment - Atenolol 50mg Q day, however, he admits to only taking it once on the day of diagnosis as he does not like to take medications.
Complications: None

Chronic low back pain

Diagnosed - March 2001 after being injured at work. MRI in March 2001 showed annular tears @ L2-L5 with disk bulges and protrusions as well as a Tarlov Cyst posterior to S2 vertebral body with mild scalloping of the posterior aspect of the vertebral body.
Symptoms – Low back pain; no neurologic manifestations.
Treatment – Initially treated with rest and physical therapy. No treatment in two years. Tylenol for flair-ups
Complications – Low back pain once a month.

Dyslipidemia

Diagnosed - March 2004 (Total cholesterol 217,LDL 171,HDL 31)
Symptoms - None
Treatment – Treated with Lovastatin 20mg po QHS. Patient only took for one month as he does not like to take medications and wanted to try to improve it with lifestyle modifications. He has not received follow-up.
Complications- None

PSH: None

Medications:

Atenolol – 50mg Q day (patient has not been taking)

Tylenol – occasionally for back pain (~ 1/mo).

No herbal medication use.

Allergies: NKDA

Social History: D.R. recently re-enlisted in army reserves. Prior to this he had been a carpenter for 20 years. He lives by himself in the Syracuse area. D.R. has been divorced for 5 years but has a teenage daughter and son who live with their mother. He has not seen either in over 2 years. He does not smoke. He has a remote history of heavy alcohol consumption, however, he has not drunk in 20 years. He denies illicit drug use and has not been sexually active since his divorce 5 years ago.

Family History:

Mother – died at 69 of breast cancer

Father – died at 62 of lung cancer (was a smoker)

Two sisters – 46, 44 – both healthy

Two children (one daughter, one son) - both healthy

No history of ischemic heart disease, hypertension or diabetes. No colon cancers or IBD in the family.

ROS:

General: Reports an intentional 20lb weight loss over the past 4 months. Denies fever, chills, malaise, fatigue, or night sweats.

Skin/hair/nails: Denies any recent rashes or skin eruptions as well as any pigmentation or texture changes. No unusual nail or hair growth.

Head: Denies any headaches, dizziness, syncope or other LOC.

Eyes: Denies changes in his visual acuity, blurring or double vision, photophobia, or pain. Does not use glasses or contacts.

Ears: Denies hearing loss, internal or external ear pain, discharge from the ear canal, ringing in the ears or vertigo.

Nose: Denies nosebleeds, postnasal drip or sinus pain or pressure.

Throat/mouth: Denies any sore throats, bleeding or swelling of the gums, recent tooth extractions, buccal or other oral ulcers.

Endocrine: Reports an intentional 20lb weight loss over the past 4 months. Otherwise denies any heat or cold intolerance, polydipsia, polyuria or changes in body or facial hair. Denies any testicular pain or problems achieving or maintaining an erection.

Lungs: Denies any cough, dyspnea, wheezing, hemoptysis or other sputum production.

Heart: Denies chest pain or pressure, palpitations, dyspnea, orthopnea, edema of the lower extremities, or exercise intolerance.

Hematologic: He denies a tendency to bruise or bleed easily or any known blood disorders in his history. He does report recent episodes of painless rectal bleeding as stated above.

Lymphatic: No enlargement or tenderness of any lymph nodes.

Gastrointestinal: Reports recent painless rectal bleeding as stated above. Denies any associated change in appetite, dysphagia, heartburn, nausea, vomiting, hematemesis. He has had a decrease in the number of bowel movements on his new diet and exercise regimen he has been following for 4 months but denies straining to have a bowel movement or any bloating.

Genitourinary: Denies dysuria, flank or suprapubic pain as well as any urgency or increased frequency of urination. No hematuria, loss of force of stream or sexual dysfunction.

Musculoskeletal: Occasional low back pain secondary to an old injury. Denies any other joint stiffness, pain or swelling. No redness of his joints or deformity. Reports a full range of motion of his joints.

Neurologic: No syncope or LOC, seizures, noted weakness or paralysis, or problems with coordination.

Psychiatric: No depression, difficulty concentrating, nervousness, or irritability.

Physical Exam:

General: Anxious Caucasian male who is well-dressed, well-nourished and with good personal hygiene. He is slightly overweight. Awake, alert and oriented. Does not appear septic or in acute distress.

Vitals: T 97.0 ; RR 20; O2Sats 98% on RA

Orthostatics: HR BP

Supine 68 150/92

Standing 77 136/75

Weight : 190lb Height: 5’10’’ BMI: 27.3

Mental Status: AAOX3. Appropriately responds to questions and behaves properly. Oriented to person, place, month, day, year, and hospital.

Skin: Skin is uniform in color. No visible tattoos or scars. Good skin turgor. Hair is fine, brown and has a typical male pattern baldness presentation with thinning on top and a receding hairline.

Head: Head midline. Scalp is pink without lesions or tenderness. Well-spaced and symmetric facial features.

Eyes: Visual acuity not tested as patient was recently tested to re-enter the Army Reserves and was told his vision is 20/20 in both eyes. Conjunctiva are clear and sclera are anicteric. PERRL3. EOMI without the presence of nystagmus. Red reflex is present and symmetric. The cornea, lens and vitreous were clear on ophthalmologic exam. The retina were without any appreciable hemorrhages or cotton wool spots.

Ears: Auricles aligned without appreciated pits, tags, lesions or masses. Tympanic membranes were gray, landmarks were clearly visible and light reflexes were present bilaterally.

Nose: Septum is midline with pink, moist mucosa. No visible lesions or polyps. No tenderness to palpation over frontal and maxillary sinuses.

Mouth: Oral mucosa is pink and moist without any lesions or ulcers. Good oral hygiene. No missing teeth appreciated nor was there any evidence of gum disease or tooth decay. Tongue and uvula midline. Pharynx was without erythema or exudates.

Neck: Supple. Trachea midline. The thyroid is not enlarged, it freely elevates with swallowing and no nodules were palpated. No JVD or carotid bruits could be appreciated. Sub-mandibular lymph nodes were palpable but not enlarged, fixed or tender.

Chest and Lungs: Chest rises and falls symmetrically. Lungs were clear to auscultation bilaterally both anteriorly and posteriorly. No accessory muscle use or retractions noted. Tactile fremitus using “99” was symmetric throughout posterior lung fields. No egophany was appreciated.

Heart: PMI was not palpable. No visible pulsations noted on observation. RRR without murmurs, rubs or gallops. S1 and S2 heard without splitting.

Vasculature: Carotid, radial, femoral and pedal pulses 2+ and symmetric. No pedal edema noted. No carotid bruits appreciated.

Abdomen: Abdomen was rounded secondary to patient being overweight. No scars, visible hernias or pulsations were observed. Bowel sounds were active in all four quadrants. Abdomen was soft and non-distended. No tenderness to both superficial and deep palpation of all quadrants and no masses were appreciated. No rebound tenderness or guarding. Liver span was percussed to be 9cm at the right midclavicular line but was not palpable under the costal margin. Spleen was not palpated or appreciated with percussion.

Rectal: No external hemorrhoids. Good tone with no tenderness or definite mass palpable. No anal fissures appreciated. Red blood visible over the exam glove.

Lymphatic: Sub-mandibular lymph nodes were palpated but not enlarged, fixed or tender. No palpable supraclavicular, axillary or inguinal nodes.

Musculoskeletal: Good tone and muscle mass throughout upper and lower extremities. No noted swelling, erythema or deformity of any joints. Active and passive ROM is excellent in all joints.

Neurologic:

CNI – not tested.
CN II – Visual acuity not tested. Fundoscopic exam illicits bilateral and symmetric red reflexes. Cornea, lens and vitreous are clear and retina has no appreciable hemorrhages. Visual field’s are equal to that of the examiners.
CN III, IV, VI – EOMI. PERRL3 with proper accomadation. No ptosis of the eyelids observed.
CN V – Jaw strength 5/5 with good buccinator tone and muscle mass. Facial sensation intact and symmetric to soft touch and sharp objects using a safety pin.
CN VII – Eyebrow’s raise, eyelid’s close and smile is symmetric.
CN VIII – not tested.
CN IX,X – Soft palate elevates symmetrically and uvula is midline.
CN XI – Shoulder shrug is symmetric and 5/5.
CN XII – Tongue extends along midline.

Sensation: Light touch and pinprick using a safety pin is intact throughout all extremities and across the torso and back. Proprioception tested through joint position of the big toe is intact bilaterally.

Strength:

D T B WE WF INT

RUE 5/5 5/5 5/5 5/5 5/5 5/5

LUE 5/5 5/5 5/5 5/5 5/5 5/5

HF Q H TA Gast EHL

RLE 5/5 5/5 5/5 5/5 5/5 5/5

LLE 5/5 5/5 5/5 5/5 5/5 5/5

Reflexes: Biceps, triceps, patellar, and Achilles reflexes are symmetric and 2+. Left and right big toes are downgoing on Babinski.

Cerebellum: RAM intact and symmetric. Finger-to-nose and heel-to-shin tests performed with ease.

Labs: 5/18/05 7:00 AM

Na 144 WBC 7.1 N 54 PT 13.1

K 3.9 H/H 38.6/13.2 L 33 INR 1.05

Chloride 106 Plt 183 M 7 PTT 27.0

CO2 28 E 4

BUN 9 B 0.4

Creatinine 0.9

Glucose 109

Nasogastric Aspirate – no evidence of blood or coffee-grounds.

5/18/05 13:00 PM

H/H 36.5/12.3

Summary Statement: The patient is a 48 year old Caucasian male with a PMH significant for hypertension and dyslipidemia who presents to the ER today with a one day history of moderate painless rectal bleeding of which the patient had two episodes in the ER. Physical exam is remarkable for the patient being overweight, orthostatic hypotension and the presence of bright red blood on the exam glove following rectal exam. Laboratory studies have shown a low H/H on presentation with a mild drop since admission.

Problem List:

Rectal Bleeding
Orthostatic Hypotension
Low H/H
Decreased Bowel Movements
Weight Loss/Nutrition/BMI 27.3
Hypertension
Dyslipidemia
Chronic Back Pain
Alcohol Abuse

Rectal Bleeding

Hematochezia is typically consistent with lower GI bleeding. This combined with the information of nasogastric aspirates being negative for coffee grounds or other overt blood lends substantial evidence to the bleed being distal to the ligament of Treitz. However, an upper GI bleed cannot be definitively excluded from the differential as rapid transit of blood from the upper gastrointestinal tract or a massive bleed in the upper gastrointestinal tract can also present with hematochezia (1). In addition, nasogastric lavage may not be positive if the bleeding is occurring distal to the pylorus and the pylorus is closed (2). Therefore both sources should be considered although the most likely location is in the lower GI tract

Lower GI Tract:

Anatomic causes of lower gastrointestinal bleeds include diverticulosis, an outpouching of the colonic mucosa and submucosa through the muscularis, leaving the already weak vasa recta exposed to further injury (1). Diverticulosis accounts for up to 50% of cases of rectal bleeding (2), being the single most common cause in patients under the age of 50 making it a strong possibility for D.R. Further evidence is lent by the fact that the majority of patients present in a similar fashion to D.R. with painless rectal bleeding without associated abdominal or systemic symptoms. Fifty percent of people have had a previous episode prior (2), however, it does not exclude this strong possibility in D.R.’s case as this may be his initial presentation or he may have had minimal rectal bleeding in the past that went unrecognized. In addition, predisposing factors include lack of dietary fiber and constipation (1), both of which are features of D.R.’s case given his recent dietary habits. The bleeding from diverticula can be minimal and only found on occult testing but as the source is arterial it more commonly is substantial as in D.R.’s case (1).

Vascular sources of lower gastrointestinal bleeds include angiodysplasia (2). Angiodysplasia is the presence of “dilated tortuous submucosal vessels” that can begin to bleed as the vascular walls degenerate with aging (1). It can account for up to 30% of lower GI bleeds (2) and may be the most common cause is patients with rectal bleeding who are over 65 (1). As with diverticular bleeds the bleeding is painless presenting with hematochezia but most commonly with guiac positive stools and iron deficiency anemia as well (1). Although D.R. does have painless rectal bleeding, he is not in the typical age group and is presenting with profuse bleeding which is not typically seen in angiodysplasia as the bleeding is venous in origin (1). Although lower on the differential based on presentation and age, it should continue to be considered due to it being such a common cause of lower GI bleeding.

Another vascular source of lower GI bleed is ischemic colitis which typically presents in the elderly and is the result of either cardiac conditions or sepsis (1). Both can lead to hypotension and hypoperfusion of the bowel (1). Although patients typically present with severe abdominal pain secondary to lack of oxygen supply, its absence does not rule this out as a cause (1).

Radiation to the bowel during treatment for abdominal neoplasms or pelvic cancers can lead to both acute and chronic injury and subsequent bleeding (1). However, as D.R. has no history of radiation exposure to these areas this etiology can be placed low on the differential.

Infectious causes of lower GI bleeding remain high on the differential for D.R.’s case given the onset occurred after he ate at a Chinese restaurant 3 days prior to the onset of the rectal bleeding. However, lack of fever, an elevated WBC count, abdominal pain or cramping does no support an infectious cause. In addition, one would expect the other customers of the Chinese restaurant who accompanied D.R. to have symptoms as well.

Other inflammatory conditions such as inflammatory bowel disease which includes both Crohn’s disease and ulcerative colitis are possibilities. They typically occur more common in the Caucasian population with an equal prevalence in men and women (3). However, D.R does not fit into the ages represented by the typical bimodal age distribution (3). Although D.R. does present with weight loss, the urge to defecate and passage of blood per rectum which often is seen in IBD, his weight loss was active and intentional. He also does not present with the typical symptoms of the insidious onset of abdominal pain, fevers and diarrhea that can contain both blood and pus and he lacks the typical extraintestinal manifestations such as arthralgias (3). In addition, the typical lab findings of someone with IBD including anemia secondary to either iron or vitamin B12 deficiency as well as an elevated ESR none of which is present in this case (3).

Neoplastic causes of GI bleeding include both colon cancer, biopsy induced or polypectomy induced during colon cancer work-ups. Ten percent of hematochezia occurs secondary to colon cancer in patients over the age of 50 (1). However, it is a rare cause in patients younger than 50 except in the presence of hereditary polyposis or non-polyposis syndromes which he does not have family history of. However, the colorectal neoplasms are typically asymptomatic until very advanced (4) and can present with blood per rectum or occult bleeding as well as the systemic symptoms of neoplasia including weight loss, anorexia, fatigue. Although he has no history of familial colon cancer and it would be rare at his age, his presentation and recent weight loss, even if intentional, merit consideration of this etiology.

Bleeding following endoscopic biopsy or polypectomy with inadequate coagulation of the stalk (1) can be excluded as the patient does not have history of having either procedure or of a coagulation disorder.

Anorectal etiologies of rectal bleeding include hemorrhoids and fissures (1). Hemorrhoids can be internal or external depending on their location with respect to the dentate line (1). Typical symptoms of hemorrhoids can include rectal bleeding, or itching. External hemorrhoids are not likely in D.R.’s case as they were not appreciated on physical exam, while internal hemorrhoids are not visible on rectal exam and remain a possibility. Although bleeding from internal hemorrhoids is typically painless as is in the case of D.R. the typical presentation is bright red blood coating the stool or blood noticed on the tissue paper after defecation (1). It may also be present in the toilet bowl staining the water red, however, copious bleeding from hemorrhoids is uncommon placing it lower on the differential in D.R.’s case.

Upper GI Tract:

Ulceration of the mucosa and underlying vessels can lead to GI bleeding in patients with esophagitis. Esophagitis is typically the result of either infections or can be induced by oral medications if they are not flushed down appropriately and have prolonged contact with the esophageal mucosa (4). Typical symptoms of both include heartburn, dysphagia and odynophagia (4) all of which D.R. denies. In addition, bleeding associated with esophagitis usually results in either hematemesis or melena. However, if the bleeding is profuse and GI transit is rapid there is a small possibility of hematochezia. He also does not have the appropriate history for either. Infections of the esophagus are usually found in immunodeficient patients and D.R. has no known history of HIV, steroid use or other immunosuppressive medications (4). In addition, he is not currently taking his prescription medications and denies taking over the counter medications including NSAIDs. However, it is not safe to totally exclude this diagnosis as D.R. has been sexually active in the past and could potentially be HIV positive without knowledge of it.

Gastritis and peptic ulcer disease represent other alterations in mucosal integrity that could ultimately lead to gastrointestinal bleeding with peptic ulcer disease being the most common cause of upper GI bleeds (4). Causes of both include H. Pylori infection, which is the most common cause, NSAID induced and stress-related (4). These diseases have the clinical presentation of abdominal pain, early satiety, nausea and vomiting and may have specific onsets in relation to meals. However, D.R. denies any of the above mentioned symptoms which you would expect. He is currently under increased stress putting him at increase risk but denies NSAID use. As mentioned above for esophagitis, bleeding would most likely present with hematemesis or melena both of which the patient denies. Due to high incidence and the possibility of profuse bleeding and increased transit time these etiologies should still be considered, however, the lack of any associated symptoms, most specifically abdominal pain, makes them less likely.

Esophageal cancer is frequently asymptomatic until in advanced stages when they typically present with progressive dysphagia (4). Although weight loss does fit the clinical picture of malignancy, D.R.’s weight loss was intentional and he reports to still having a good appetite. Although usually only seen in the later stages, he also denies symptoms such as chest pain, cough or hoarseness (4). The types of esophageal cancer include squamous cell in the proximal 2/3 and associated with drinking and smoking and adenocarcinoma present in the distal 1/3 and associated with long-standing history of reflux disease. D.R. denies symptoms or reflux disease, however, he does have a social history significant for heavy alcohol use predisposing him to squamous cell carcinoma. Again it is unlikely bleeding from esophageal cancer would present with hematochezia, however, his weight loss (although intentional) in combination with his history of alcohol abuse and the silent nature of early disease make this an etiology worth investigating.

As with esophageal cancer, gastric cancer can also cause gastrointestinal bleeding. Risks for gastric cancer include being male, poor nutritional intake as well as diets high in nitrates, and pre-existing conditions such as gastritis (4). Symptoms include abdominal pain, early satiety, nausea, vomiting and weight loss. D.R. is male and has recently had poor nutritional intake as he is trying to lose weight and has, however, his poor nutritional intake is likely not a predisposing factor as it is recent and isn’t likely to cause gastric carcinoma in such a short time frame. In addition, his weight loss was intentional and he denies all other associated manifestations. Again, upper GI bleeding usually would not present with hematochezia. All things considered this is low on the differential.

Esophagogastric varices are the result of portal hypertension and can present with gastrointestinal hemorrhage including hematochezia. The patient has risks for portal hypertension given he has a history of alcohol abuse. You would expect D.R. to have other symptoms of portal hypertension such as hemorrhoids, caput medusa which were not appreciated on physical exam. You would also expect D.R. to have hematemesis if the bleed was significant enough to cause hematochezia. Although this is probably not the etiology his social history warrants consideration.

Mallory-Weiss Tear usually present with hematemesis following a history of severe retching. D.R. does not have a history of hematemesis or retching at all making this less likely a possibility. In addition, one would not expect a bleed from Mallory-weiss tears to produce hematochezia without hematemesis.

Hypertension

There is substantial evidence available that treating hypertension, even mild, is beneficial. Recently the NHANES II study showed that in patients less than 65 y/o, “increases in systolic blood pressure were linearly related to increases in cardiovascular and all-cause mortality at all diastolic blood pressures (5).” In addition, the Framington Heart Study reported that even “patient’s with high-normal values (130-139/85-89) had increased hazard ratios for a cardiovascular event compared to optimal blood pressure (5).” D.R. was diagnosed with hypertension recently in March of this year but has not been taking his medication. Evidence from the above mentioned studies shows he is at increased risk for cardiovascular events and higher overall mortality and therefore he should be educated on this and together his blood pressure should be tackled aggressively in a manner with which the patient will be compliant.

Plan:

1. GI – Patient presents with new onset of moderate hematochezia since yesterday afternoon.This is probably due to a lower GI bleed as the blood is bright red and there was no blood found in the nasogastric aspirate. The patient is not currently bleeding and is stable at this time. At this time the patient will be admitted to the floor and prepped with 1 gallon of Golytely and kept NPO overnight for colonoscopy in the AM. If this is unremarkable we will proceed with an upper GI endocscopy as an upper GI source cannot be fully excluded although less likely. Stool cultures will also be done to look for possible infectious sources. H/H will be drawn q6h. If the patient becomes hemodynamically unstable, bleeds heavily again or drops his H/H significantly a stat RBC scan should be done to identify the source. Do not give patient NSAIDs.

2. Hematologic – Patient’s H/H has decreased minimally since admission. He is stable at this time and asymptomatic. Serial H/H will be drawn q6h as stated above and any significant change warrants a stat RBC scan. The patient should be type and cross matched and transfused if needed.

3. F/E/N – Patient is dehydrated as he has orthostatic hypotension and moderate blood loss from his rectal bleeding. Two large bore IV lines are in place. Continue IVF at 100cc/hr. Patient should be kept NPO overnight for colonoscopy in AM. The patient reports poor eating habits and nutritional intake with an intentional 20lb weight loss over the past 4 months. He should be seen by a nutritionist prior to discharge to be educated about healthy weight loss options.

4. CVS – Patient was recently diagnosed with hypertension and placed on Atenolol although he only took a single dose the first day and has not taken any since. His cholesterol panel in 2001 showed dyslipidemia and he took Lovastatin 20mg po QHS for only a month as he does not like to take medications and thought he could control it with diet and exercise. The patient has lost 20lb in the past four months which could be improving both his blood pressure and cholesterol, however, his blood pressure today is elevated and his cholesterol has not been repeated since 2001. As stated above several studies have shown the importance of both blood pressure control and cholesterol levels in relation to cardiovascular complications and mortality. This evidence should be discussed with the patient and the importance of blood pressure control emphasized. He should continue taking Atenolol 50mg QDay and a follow up appointment will be scheduled for him in one month, however, this will be discussed. If the patient seems unlikely to be compliant alternative treatment routes will be explored. Fasting total cholesterol, LDL, HDL and triglycerides will be ordered with tomorrows labs and the need for treatment will be re-assessed based on those results.

5. Musculoskeletal – Patient has a history of chronic back pain secondary to a work related injury in 2001. He only complains of mild low back pain once a month that is relieved with Tylenol and has good range of motion on physical exam. However, given his presentation of a GI bleed caution should be taken to treat the back pain with NSAIDs when it occurs. In house he will be prescribed Ultram 50mg q6h prn as needed.

6. Preventative Health – Encourage good hand-washing techniques and monthly self-testicular exams. If unremarkable today colonoscopy should be repeated in 10 years with occult blood tested yearly. As he is re-enlisting in the Army living quarters should be discussed and possibility of the need for the meningitis vaccine. Encourage patient to attend AA meetings for continued abstinence from alcohol use.

References

Saab, Sammy, M.D. and Rome Jutabha, M.D. “Approach to the patient with lower gastrointestinal bleeding.” www.utdol.com. June 15, 2005.
Sabb, Sammy, M.D. and Rome Jutabha, M.D. “Etiology of lower gastrointestinal bleeding.” www.utdol.com. June 15, 2005.
Faselis, Charles J, M.D and Conrad Fischer, M.D. Kaplan Medical USMLE Step 2 CK Lecture Notes. “Internal Medicine.” Kaplan, Inc. 2004: 1-32.
Andreoli, Thomas E, M.D, et al. Cecil Essentials of Medicine. W.B. Sanders Company; Philadelphia, PA; 2004: 313-428.
Kaplan, Norman, M.D. and Burton Rose, M.D. “Hypertension: Who should be treated?” www.utdol.com. June 16, 2005.