HISTORY:
Rectal bleeding for
Type:
Volume:
Episodes: times
Treatments tried: ,
, , ,
, episodes ,
, episodes ,
, over ,
Other elements:
Last colonoscopy: ago
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Anorectal: DRE , prostate , anus
Extremities: , , cap refill , pulses ,
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , ,
- Stools: , , ,
- Abdominal ultrasound
- Colonoscopy
- CT scan of abdomen and pelvis
-
- Increase fluid intake
- Increase dietary fiber
- Stop anticoagulants
- 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
- Go to ER if severe abdominal pain, severe vomiting, or fever occurs