CHIEF COMPLAINT: Rectal pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who states that he has had rectal pain that started 7 days ago after he was very constipated and a large bowel movement came out. He says that he felt like he cut himself as this occurred.
He was seen and evaluated in the clinic by Dr. John Doe, diagnosed with rectal fissures. The patient was prescribed some medicine for his rectum, but he did not think it helped.
The patient says that he did not know how much of cream he is supposed to put in, and he has also been taking some laxatives, so he says his constipation seems to have resolved. He is also taking prune juice.
PAST MEDICAL HISTORY: History of depression, hypertension, diabetes, and anxiety.
SOCIAL HISTORY: He is retired. He is single.
FAMILY HISTORY: Noncontributory.
MEDICATIONS: Metformin and insulin.
ALLERGIES: Sulfa and penicillin.
REVIEW OF SYSTEMS:
GASTROINTESTINAL: The patient reports that he is not having any pain towards his belly. He has not been vomiting.
CONSTITUTIONAL: The patient denies fevers or chest pain. There were no systemic complaints.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 36.2, pulse 90, respiratory rate 16, blood pressure 122/94, and pulse ox 96% on room air, which is normal.
GENERAL: This is a (XX)-year-old male who is sitting upright.
HEENT: Normocephalic. Pupils are equal and reactive. The patient’s oropharynx is clear.
LUNGS: Clear.
HEART: Regular rate and rhythm.
ABDOMEN: Soft, nondistended, and nontender.
RECTAL: The patient’s rectal exam was done with the nurse present. In fact at that time, he also had anoscopy that was done and it showed that there is an area of small rectal fissures that are present across the superior left of the rectum without any current bleeding. The patient has no palpable hemorrhoids that are present on rectal exam digitally.
DIFFERENTIAL DIAGNOSES: Rectal fissures, constipation, and local trauma.
EMERGENCY DEPARTMENT COURSE: The patient denies any type of local trauma except for trying to pass this larger stool and the only thing that I see on exam after anoscopy is rectal fissures. The patient has been given the information to follow up with the on-call surgeon, if his pain is not improving.
We have written for Anusol-HC suppositories, a total of 20 dispensed, see if he will do a little better with the suppositories and the cream. Also, he was given 15 Lortab as prescription. We have recommended Metamucil rather than laxatives at home.
DIAGNOSES:
1. Rectal fissures.
2. Diabetes.
DISPOSITION: Discharged.
DISCHARGE CONDITION: Good.
