If the аttоrneys dо nоt object to heаrsаy testimony, it will result in the admission of hearsay evidence.
Assessment аnd Plаn: HPI: This is а 67-year-оld male patient whо presents with the cоmplaint of blood in his stool intermittently over the last 4 months. At first, the pt reported having small amounts of occasional bright red blood in his stool. The frequency of this increased from once per week, to 2-3 times per week now. This last episode of blood in the stool occurred two days ago. Pt denies black or “tarry” stool. Pt describes the stool with bright red blood “mixed in”, when the episodes are actively occurring. Pt reports also having constipation several times per week, which is new for him over the last 6 months. Pt reports some relief of this by taking an over-the-counter stool softener. Stools are otherwise described as thin and brown when neither constipation or blood is present. No specific time of day seems to make the issue worse. He denies any pain with defecation. Pt denies any other known exacerbating or alleviating factors. Pt does not currently take any blood thinners or aspirin. He also denies recurrent use of NSAIDs or OTC pain medications. Pt adds that he has been having some new associated generalized fatigue over the last month and reports that it feels harder to exert himself when he is outside doing yard work (such as shoveling or raking). Otherwise, pt reports being able to do his normal activities of daily living. No syncope, dizziness, passing out, chest pain, or general sense of shortness of breath. Pt also denies associated abdominal pain, rectal pain, nausea/vomiting, dysuria, hematuria, flank pain, or preceding trauma or injury. No easy bruising or bleeding otherwise. Pt denies hx of similar symptoms in the past prior to 4 months ago. Pt denies any dietary intake of beets or red-colored drinks recently or prior to onset of these symptoms. He denies any history of hemorrhoids. No history of rectal trauma. Medications: Lisinopril 10mg, one tablet taken PO daily Metformin 500mg, one tablet taken PO twice daily Docusate sodium 100mg PO, one tablet taken PO daily Atorvastatin 80mg, one tablet taken PO QHS Allergies: No known medication or environmental allergies Past Medical History: Chronic conditions: Obstructive sleep apnea (OSA) (diagnosed 8 years ago) - uses CPAP nightly Diabetes Mellitus Type 2 (diagnosed 18 years ago) Primary Hypertension (diagnosed 20 years ago) Hyperlipidemia (diagnosed 20 years ago) Obesity (diagnosed 25 years ago) Surgeries: None Immunizations/Health maintenance: Up-to-date on recommended, age-appropriate vaccines including COVID, influenza, Tdap, pneumovax, and shingles. Pt denies ever getting a colonoscopy in the past, sharing that he is fearful of medical procedures ever since his father passed from complications related to a “routine surgery”. Pt did opt to have fecal immunochemical test (FIT) testing, which was last done just over 3 years ago and was negative at that time. Pt’s last routine diabetic eye exam was 2 years ago. Family History: Father: Deceased from complications related to a “routine surgery” at 58 years old. Pt was unable to provide more details about the surgery. Known hx of hyperlipidemia, obesity, diabetes, diverticulosis, and coronary artery disease Mother: Alive, 89 years old. Known hx of obesity, colorectal cancer s/p surgical resection and successful treatment, also has a hx of hypothyroidism Sister: Alive, age 62, Known hx of COPD, breast cancer (s/p chemotherapy and successful treatment), hyperlipidemia Children: Two children, both alive and well Child 1 (male): Age 41, healthy, with two children of his own Child 2 (female): Age 39, healthy, no children Social History: Tobacco/Vape: Quit 30 years ago, was a one-pack-per-day smoker for 5 years. No vaping. Alcohol: One or two beers occasionally on the weekend. Pt does not exceed 2 drinks per week. Illicit drugs: Denies drug use Marital/Sexual: Pt is married, only sexually active with her wife of 30 years. No anal intercourse. Living situation: Lives with her husband in their long-term home just south of Carlsbad Job: Retired UPS worker Hobbies: Gardening, playing guitar. Diet: Following the “Mediterranean diet” in attempts to lose weight Religion: Christian Sleep: Averages 7 hours of sleep per night ROS: Constitutional: See HPI. Additionally, pt admits to 20lb weight loss over the last 6 months, adding that he attributes this to following a better diet. Denies night sweats, weight loss, or weight gain recently. Skin: Denies hair loss, nail pitting, rashes, lesions, or skin discoloration. HEENT: Positive for sore throat after coughing. Denies rhinitis, congestion, ear pain or discharge, eye pain, or change in vision. Denies epistaxis. Denies hearing loss, tinnitus, or nasal discharge. No lymph node or gland swelling reported. CV: See HPI. No palpitations, no unilateral leg swelling, or edema of lower legs. No syncope or presyncope reported. Pulmonary: See HPI. No orthopnea noted. No hemoptysis. GI: See HPI. Denies constipation, diarrhea, abdominal pain, distention, or heartburn. GU: See HPI. Denies urinary frequency hesitancy, or urgency. Denies incontinence. MSK: Denies trauma, joint swelling or joint pain, arthralgias or myalgias. Denies back pain. Neuro: See HPI. Denies headaches, speech changes, slurred speech, or focal weakness. Denies seizures, tremors, or confusion. Psych: Denies depression or anxiety Endocrine: Denies heat or cold intolerance, polyuria, polydipsia, or polyphagia. Heme/Lymph: Denies easy bruising or gum bleeding. Physical Exam Findings: VITAL SIGNS: Temperature: 37°C (98.6°F) Pulse rate: 95 Respiration Rate: 19/min Blood pressure: 130/82 mmHg. Oxygen saturation: 97% on room air Weight: 100 kg (220 lb) Height: 175 cm (69 in) GEN: Well-developed, well-nourished, overall well-appearing male. No acute distress noted. Patient is alert/oriented appropriately. HEENT: Mucous membranes moist, without lesions. PERRLA, EOMI B/L with palpebral conjunctival pallor noted. NECK: Neck is supple, no masses, trachea midline, no thyroid nodules, or masses. No LAD, lymph node tenderness or enlargement. SKIN: No cyanosis or pigment changes appreciated, without obvious lesions or rashes, nail clubbing. Normal skin turgor. Normal hair pattern and texture. No bruising or skin abnormalities noted. HEART: Regular rate, regular rhythm with normal S1, S2, without rubs, murmurs or gallops auscultated. No JVD, no displacement of PMI; no carotid or abdominal bruits. LUNGS: CTA B/L, no appreciable wheezes, rhonchi, or rales. No noted increased respiratory effort or accessory muscle use. No stridor noted. PERIPHERAL VASCULAR: Capillary refill slightly delayed throughout distal extremities, at ~3s. No peripheral edema. Pulses 2+ and intact at DP, PT, brachial and radial B/L. No digital clubbing noted. ABD: Normoactive bowel sounds heard throughout all quadrants. Soft abdomen without tenderness noted to light or deep palpation throughout. No rebound or guarding noted. No hepatosplenomegaly noted. No abdominal bruits or pulsatile masses noted. GU/Rectal: Digital rectal exam notes non-boggy, non-tender, smooth prostate. Size appropriate for age. No palpable rectal masses appreciated internally or on visual exam externally. No immediately appreciable external hemorrhoids, or fissure(s). Point-of-care hemoccult (stool guaiac) testing was positive. NEURO: Pt alert and oriented x 4, following commands appropriately. Speech clear and without slurring. Gait steady and without limp or need for assistance. No facial asymmetry. Strength 5/5 throughout all extremities without gross motor deficit. CN 2-12 intact. PSYCH: Judgment and insight intact; no confusion. EKG (previously provided): (Note: This EKG is a standard 10-second recorded EKG strip) Diagnostic Results: Based on your review of the information provided above: (Q1.) Please report the most likely final top diagnosis that explains the patient's reason for visit. (Q2.) Please provide a disposition for this patient based on your diagnosis. [PLO 2] (Q3.) Please describe the components of the management for the patient’s top final diagnosis and any other acute problems. This must include any applicable pharmacologic and non-pharmacologic treatments. (Note: “Non-pharmacologic” = non-medication based treatments, patient education, referrals, and/or follow up needs). [PLO 4] (Q4.) Please create a comprehensive problem list of any remaining acute and chronic problems for the patient in this case. You do not need to include the top final diagnosis, since that was previously provided. [PLO 5d] (Q5.) Finally, list and describe the components of management for any of the patient’s remaining problem list items not previously addressed. This must include any applicable pharmacologic and non-pharmacologic treatments (Note: “Non-pharmacologic” = non-medication based treatments, patient education, referrals, and/or follow up needs). [PLO 4] For the purposes of this exam: "Acute" is defined as: any immediate management needs or adjustments to the patient’s current plan of care. "Chronic" is defined as: management after the current visit and into the foreseeable future. This could include (but is not limited to): Care for on-going medical problems, follow up, referral(s), additional diagnostics needed for this patient in the future, health maintenance screenings, or other long-term therapeutics.
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