1NURS 6512 N-24 Advanced Health AssessmentWeek 10 Discussion Post – Assessing the Genitalia and RectumCynthia NwokochaJuly 31, 2017Review of Case #1: Rectal BleedingA 62-year-old male construction worker reports to your clinic after experiencing rectal bleeding for over 1 month. He has noticed small amounts of blood after every bowel movement. He had a colonoscopy 2 years ago with normal results. The patient has no fever, chills, dysuria, abnormal urinary frequency, or abdominal pain. The patient reports occasional rectal itching and pain. Hestates he has no noticeable sores on his rectal area and no family history of colorectal cancer.Patient Initials: DOAge: 62Gender: MaleRace/Ethnicity: Black/AfricanSUBJECTIVE DATA: Chief Complaint (CC): “I am having rectal bleeding.”History of Present Illness (HPI): DO is a 62-year-old African male that presents to the clinic today with complaints of having rectal bleeding for the past month. He states that he notices spots of bright red blood on Tucks pad after each bowel movement. He states a5 year history of constipation off and on. States it has gotten worse the past two months. States he has a bowel movement twice per week and it is hard and dry. He reports having occasional rectal pain with defecation and rectal itching that occurs after every BM. He rates his pain at present time as 2/10, and a 7/10 with a bowel movement. He denies having any sores on rectal area but does feel a sensation of a lump in anal area. He states that he also notices reddish brown stains in his underwear. He states that the bleeding becomes worse the longer he sits on the toilet. He has been using Tucks pads to wipe withto help soothe the pain and states that this helps. He has also been using Preparation H forthe itching and states that it works great. He states that straining makes the pain worse. He denies fever, chills, dysuria, abnormal urinary frequency, or abdominal pain. He has a colonoscopy 2 years ago with normal results. He denies seeing any clots. He states that he is a construction worker and is on his feet all day. He states that his diet consists of fastfood and caffeinated drinks. He denies drinking water. Medications: Viagra 50 mg once per day as needed; and Allergies: NKDA. No known environmental or food allergies
2Past Medical History (PMH): Constipation- diagnosed in 2012. Erectile Dysfunction- diagnosed in 2013. Past Surgical History (PSH): Left knee arthroscopy in 2013Sexual/Reproductive History: Heterosexual; married for 40 years. Sexually active, but does suffer from ED. Denies history of STDs/STIs. Denies using condoms. Personal/Social History/lifestyle: DO was born in Nigeria. And had moved to Texas about 4 years ago with his family. He completed school through 12thgrade. He works in construction. He is exposed to harmful chemicals and loud noises on a daily basis. He married at age 22. He and his wife have been married 40 years. He has a 20 pack/year smoking history. Drinks one glass of bourbon every night before bed. Denies illicit drug use. States he has worked in construction for the past 30 years, working 12 hour days, 5
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