REASON FOR VISIT: Symptomatic hemorrhoids.
HISTORY OF PRESENT ILLNESS: The patient is a very pleasant (XX)-year-old gentleman who was referred here by Dr. (XX) for symptomatic hemorrhoids. The patient states that he has had a long history of problems with hemorrhoids with some burning, itching, and minor bleeding that he has put up for a quite a long time. It has not been a major issue except for the last two months. The bleeding has worsened. The pain has worsened and the discomfort that he has. He saw the gastroenterologist who did perform a colonoscopy, and he was found to be clear, except for his hemorrhoids. He was given some cortisone suppositories as well as sitz bath, and attempt was made trying to get this better with this conservative management as well as stool softeners. Unfortunately, he has continued to have problems with more bleeding, lot of pain, lot of itching, very uncomfortable to move his bowels. As his bowels move, he says he has a lot of discomfort. Sitting down is even uncomfortable. He does have a family history significant for some GI issues. He has an uncle and a brother with Crohn disease and a mother who had colon cancer.
PAST MEDICAL HISTORY: His medical history is mostly significant for a trauma that he sustained at work and ended up with a neurogenic bladder, sleep apnea, and myalgias. This was going back to the year (XX). He also has a history of traumatic brain injury from this. He also has a history, two years ago, of having a DVT and a PE and has been chronically anticoagulated since then. He suffers from hypertension, type 2 diabetes, gastroesophageal reflux disease, depression, gout, and benign prostatic hypertrophy.
PAST SURGICAL HISTORY: Surgeries have been limited to the suprapubic tube that he has for his neurogenic bladder as well as some rotator cuff surgery.
ALLERGIES: Not to any medicines, except apparently one of the STATINS he took he had a problem with, but it was not true allergy.
MEDICATIONS: His medication list includes fluoxetine 20 mg daily, lisinopril 10 mg daily, verapamil 240 mg daily, omeprazole 20 mg daily, Lipitor 20 mg daily, glimepiride 2 mg daily, metformin 500 mg daily, Coumadin 5 mg daily, clonazepam 1 mg daily, gabapentin 300 mg 3 times a day, and morphine sublingual 100 mg.
SOCIAL HISTORY: Positive for smoking, but he stopped 12 years ago and denies any significant alcohol intake.
FAMILY HISTORY: Positive for GI problems, including Crohn disease in a brother and an uncle and colon cancer in his mother.
REVIEW OF SYSTEMS: Negative for any problems with his vision. No problems with his ears, nose, and throat presently. No problems with his cardiovascular, respiratory or GI. GU: He has a neurogenic bladder as noted above with a suprapubic tube, but otherwise, he is asymptomatic from that now. He does get pains in this area and that is what most of his pain medication is for. He denies any musculoskeletal or joint issues. Denies any skin rashes or skin lesions. Denies any psychiatric problems, except for the depression that he has and neurologically only complaint again is the neurogenic bladder.
PHYSICAL EXAMINATION: GENERAL: This is a (XX)-year-old gentleman who looks his stated age, in no acute distress. HEENT: Normocephalic and atraumatic. Ears, nose, and throat are clear. NECK: He has no cervical or clavicular adenopathy. LUNGS: Clear bilaterally. HEART: Regular rate and rhythm with normal S1 and S2. ABDOMEN: Completely soft and nontender. He does have a suprapubic tube in place that seems to be draining clear yellow urine. EXTREMITIES: Have no major deformities. There is no pitting edema presently. No sequelae of chronic venous insufficiency even with a history of DVT. NEUROLOGICAL: He is alert and oriented x4. Sensory and motor functions were screened and were intact. RECTAL: Rectal exam was performed. Anal inspection revealed no external skin tags or external hemorrhoids. A proctoscope was placed. The patient does have significant grade 2 hemorrhoids in all three quadrants that are slightly tender. We could not visualize a fissure at this time.
IMPRESSION AND PLAN: The patient has symptomatic grade 2 hemorrhoids. He has tried conservative management and he is not doing well with this. Another recommendation could be nonsteroidal antiinflammatory. Unfortunately, we do not think this is good with his diabetes and we would not recommend this. Because of this, we think banding of the hemorrhoids is a treatment option. We are not going to stop his anticoagulation with a history of deep venous thrombosis and pulmonary embolism. We think banding of the hemorrhoids themselves should not cause major bleeding. When they do shed themselves in two to five days after placement, we explained that he may have some bleeding that may be little bit more than usual but hopefully should not be too excessive. We think the risk of significant bleeding is small compared to risk of stopping his Coumadin, which could end up with recurrent deep venous thromboses and pulmonary embolisms, which could be life threatening. We talked about this. He has agreed to proceed without stopping the Coumadin and he is tentatively scheduled for surgery on (XX).
