RT1 – Surgery

S:

53 y/o M, with a history of CHF, HTN and perianal lesion, who presented to the ED c/o bright red blood rectal bleeding that started two hours ago. Patient states he had a colonoscopy and biopsy of the lesion three days ago at Mount Sinai. He states he was informed that he has rectal cancer with plans to start chemotherapy next week. Patient reports he has had the lesion for years and had a negative biopsy for rectal cancer in 1985. He reports a large amount of bleeding but cannot quantify it and denies any alleviating or aggravating factors. He reports rectal pain and weakness but denies fever, chills, fatigue, nausea, vomiting, abdominal pain, dizziness, lightheadedness or other symptoms at this time. 

PMHx: CHF, HTN, perianal lesion

PSHx: rectal biopsy in 1985 and 2021

Family Hx: no family history of cancer  

Allergies: NKDA

Medications: Atorvastatin 40mg PO once a day, Carvedilol 25mg PO twice daily with meals, Furosemide 40mg PO twice a day, Hydralazine 100mg PO twice daily, Isosorbide mononitrate 120mg PO daily, Oxycodone-Acetaminophen 10-325 mg PO every four hours PRN

FHx: non-contributory

SHx: Nonsmoker, no alcohol or illicit drug use. 

O:

VS: Temp 97.9 F, Pulse 79 bpm, BP 132/75, RR 18 breaths/minute, O2 sat 100% on room air, Ht 6’0”, Wt 193 lb, BMI 26.18

PE:

General: Alert and oriented x3, ill-appearing, appears older than stated age

HEENT: no gross abnormalities

CV: Regular rate and rhythm, no murmurs.

Pulm: Clear to auscultation bilaterally

Abd: Flat, symmetrical, soft, nontender, nondistended

Rectal: rectal mass in perianal area with copious amount of bleeding, patient has pain with mild movement and refuses further evaluation of the area

Labs:

13.41 | 10.4 | 394                              137| 101| 35       102                          PT: 13.3

34.2                                         5.1 | 26 | 1.64                                     aPTT: 36.8

A:

53 y/o M, with a history of CHF, HTN and perianal lesion, who presented to the ED c/o rectal bleeding that started two hours ago. Patient states he had a colonoscopy and biopsy of the lesion three days ago at Mount Sinai positive for rectal cancer, with initiation of chemotherapy next week.

P:

Admit to surgery. OR tonight for perianal examination under anesthesia and control of the bleeding.

Keep NPO

Continue IV fluids and pain control

Trend H&H, strict Is and Os

DVT prophylaxis with SCDs

Rigid sigmoidoscopy

Admit to step-down unit