Rectal Bleeding
Age: years old
Gender:
HISTORY:
Presents with a - history of rectal bleeding
Described as
Blood volume estimated as
Occurred times
Alleviating factors: ,
Associated symptoms: *Try using right-click for negatives*
, , ,
, episodes ,
, episodes , ,
, over ,
Contributing factors:
no history of: , , , ,
no use of: ,
no family history of:
last colonoscopy: ago
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , , , bowel sounds , ,
Anorectal: DRE , prostate , , , anus
Extremities: , , cap refill sec, pulses , ,
ASSESSMENT:
DDx: hemorrhoids, anal fissure, colorectal cancer, gastrointestinal infection, inflammatory bowel disease, diverticulosis, angiodysplasia, polyps, ischemic colitis, proctitis, solitary rectal ulcer syndrome, radiation proctitis, anticoagulant medication side effect, coagulopathy, rectal trauma, upper gastrointestinal bleeding with rapid transit, meckel's diverticulum, endometriosis involving the bowel, post-polypectomy bleeding
PLAN:
Investigations:
- Blood work: , , , , ,
- Stools: , , ,
- Abdominal ultrasound
- Colonoscopy
- CT scan of abdomen and pelvis
Treatments:
-
- Increase fluid intake
- Increase dietary fiber
Further care:
- Referral to gastroenterologist
- Referral to general surgeon
- Follow-up in
- Return if bleeding worsens, if new symptoms develop such as abdominal pain or weight loss, or if symptoms do not improve with treatment
- Referral to ER if severe abdominal pain, severe vomiting, or fever occurs
HISTORY: Associated symptoms: EXAM: ASSESSMENT: PLAN: