Clinical Case Presentation

instructions:

-post one interesting case that he/she has seen in the clinical setting

-The case should be posted in the SOAP format, with references for the patient diagnosis, differential diagnoses (there should be at least 3), and the treatment plan.

-The posting does not have to be written in APA format, but should be written with correct spelling and grammar.

-Please use attached soap note for clinical presentation

  Running head: 1498-20200217-001.
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Soap Note # 6. Main Diagnosis: Anal fissure, unspecified ICD 10: K60.2.
Student Name: Calderon, Frank.
Florida National University.
Date of Encounter: 02/17/2020.
Clinical Site: De La Calle Medical Center.
Instructor: Yudith Diaz.
1498-20200217-001.
PATIENT INFORMATION
Name: Mr. Y.G.
Age: 62-year-old
Gender at Birth: male
Gender Identity: male
Source: Patient
Allergies: calamary seafood.
PAST MEDICAL HISTORY: None.
INMUNIZATIONS: Vaccine updated, TT 2016.
CURRENT MEDICATION: None.
SURGICAL HISTORY: None
FAMILY HISTORY: Mother: Obesity, Father: pancreatitis chronic.
SOCIAL HISTORY: Spanish speaker. Mechanic. 1 son. Denies illicit drugs, never smoke or
drink. Low sodium, cholesterol and carb diet.
Sexual Orientation: heterosexual.
Nutrition History: No seafood.
Subjective Data:
CHIEF COMPLAINT: “I have bleeding when I push to defecate frequently”.
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HISTORY OF PRESENT ILLNESS: 62-year-old Hispanic male coming to the clinic
complaining of having problems going to the bathroom. He reports that he has bleeding when
push to defecate, sometimes he bleeds a lot and in others very little, he denies having pain, he
has been suffering from this for a couple of months ago. Denies fever, or any type of stomach or
digestive disorders, does not suffer from psychiatric, sexual, or kidney diseases, denies diarrhea
or constipation.
Review of Systems (ROS)
CONSTITUTIONAL: Denies fever or chills. Denies weakness or weight loss.
NEUROLOGIC: Headache and dizziness as describe above. Denies changes in LOC. Denies
history of tremors or seizures.
HEENT: HEAD: Denies any head injury, or change in LOC. Eyes: Denies any changes in vision,
diplopia or blurred vision. Ear: Denies pain in the ears. Denies loss of hearing or drainage. Nose:
Denies nasal drainage, congestion. THROAT: Denies throat or neck pain, hoarseness, difficulty
swallowing.
RESPIRATORY: Patient denies shortness of breath, cough or hemoptysis.
CARDIOVASCULAR: No chest pain, tachycardia. No orthopnea or paroxysmal nocturnal
dyspnea.
GASTROINTESTINAL: Denies abdominal pain or discomfort. Denies flatulence, nausea,
vomiting, complaining of having problems going to the bathroom, he has bleeding when push to
defecate, and no anal pain.
1498-20200217-001.
GENITOURINARY: Denies hematuria, dysuria or change in urinary frequency. Denies
difficulty starting/stopping stream of urine or incontinence. No bleeding.
MUSCULOSKELETAL: Denies falls or pain. Denies hearing a clicking or snapping sound.
SKIN: No change of coloration such as cyanosis or jaundice, no rashes or pruritus.
Objective:
Physical Examination:
VITALS SIGNS:
Blood Pressure 138/85 mmhg, Pulse 80, x min; Respiration 16 min, Temperature 97.8 F,
O2 saturation 100 % at room air. Weight: 170 lbs. Height: 5’8” BMI: 30.5
Pain level: 2/10
HAIR: normal hair distributions, no hair abnormalities reported.
NAILS: No nails discoloration, no clubbing, no cyanosis or another deformity.
HEENT/HEAD: Patient norm cephalic, not deformity. Atraumatic.
EYES: PERRLA. Extraocular movements intact. No glasses, no diplopia, no secretion. Denied
visual problems.
NOSE: No nasal congestion or running nose. Patient denies postnasal drip, changes in sense of
smell, obstructions or nose bleeds.
THROAT/MOUTH: Denies sore throat, no hoarseness, no difficulty swallowing, and no
postnasal drip. No mouth sore, no thrush, no bleeding gums, no lips sore, no teeth problems.
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NECK: Denies neck pain, no masses, no nodules, no history of thyroid abnormality. No JVD
RESPIRATORY: No wheezing or respiration distress. Lungs sound clear in all lobes.
CARDIOVASCULAR: Denies chest pain, palpitations, no orthopnea. Symmetrical chest
expansion. No murmur, gallop or rale. PMI located at 5th intercostal space at mid clavicle line,
towards the left, S1 and S2 present with no change. No rubs, no bruit. No Peripheral edema.
Denied claudication or pain.
NEUROLOGIC: AAO x 3, follow commands. Neurologic grossly intact. Present reflex. No
sensory alteration.
INTEGUMENTARY: SKIN: No rash, or erythema, no change on skin color or texture in the rest
of the body, no dry skin, no jaundice.
GASTROINTESTINAL: Abdomen no distended, BS presents in all 4 quadrants. No masses,
guarding or rebound.
Anus: presence of open small lesion, about 2 mm in diameter, does not bleed, does not cause
pain on palpation, no masses around it, rectal touch: external and internal sphincters present
without pathological alterations. Fecal material in rectum, palpable prostate, normal size. The
presence of hemorrhoids is ruled out.
GENITOURINARY: Denies dysuria, frequency, urgency, hesitancy, incontinency or hematuria.
EXTERNAL GENITALS: Normal appearance
MUSCULOSKELETAL: Patient denied fall, contractures or fractures. Denied joint pain.
PSYCHIATRIC: Patient denied feel depression at time, irritability, no mood swing, sleep
disturbances or hallucinations.
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ENDOCRINE: No excessive sweating, no cold/hot intolerance, no hot flashes, no abnormal
thirst/ hunger/appetite, normal urinary habits.
HEMATOLOGIC/LYMPHATIC: Denies history of anemia, no bruising, no abnormal bleeding,
and no swollen glands.
DIAGNOSIS:
Anal fissure, unspecified ICD 10: K60.2; an anal fissure is a break or tear in the skin of the
anal canal. Anal fissures may be noticed by bright red anal bleeding on toilet paper and
undergarments, or sometimes in the toilet. If acute they are painful after defecation, but with
chronic fissures, pain intensity often reduces. Anal fissures usually extend from the anal opening
and are usually located posteriorly in the midline, probably because of the relatively unsupported
nature and poor perfusion of the anal wall in that location. Fissure depth may be superficial or
sometimes down to the underlying sphincter muscle. Untreated fissures develop a hood like skin
tag (sentinel piles) which cover the fissure and cause discomfort and pain. [Sadovsky, R. 2015].
DIFFERENTIAL DIAGNOSIS
Hemorrhoid, ICD 10: K64.9, Hemorrhoids, also called piles, are vascular structures in the anal
canal. In their normal state, they are cushions that help with stool control. They become a disease
when swollen or inflamed; the unqualified term “hemorrhoid” is often used to refer to the
disease. The signs and symptoms of hemorrhoids depend on the type present. Internal
hemorrhoids often result in painless, bright red rectal bleeding when defecating. External
hemorrhoids often result in pain and swelling in the area of the anus. If bleeding occurs it is
usually darker. [Sadovsky, R. 2015] Symptoms frequently get better after a few days. A skin tag
may remain after the healing of an external hemorrhoid
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Anal fistula, ICD 10: K60.3; Anal fistula is a chronic abnormal communication between the
epithelialized surface of the anal canal and usually the perianal skin. An anal fistula can be
described as a narrow tunnel with its internal opening in the anal canal and its external opening
in the skin near the anus. Anal fistulae commonly occur in people with a history of anal
abscesses. They can form when anal abscesses do not heal properly. Anal fistulae originate from
the anal glands, which are located between the internal and external anal sphincter and drain into
the anal canal. If the outlet of these glands becomes blocked, an abscess can form which can
eventually extend to the skin surface. The tract formed by this process is a fistula. Abscesses can
recur if the fistula seals over, allowing the accumulation of pus. It can then extend to the surface
again – repeating the process. (Gupta PJ, 2014).
Ulcerative colitis, unspecified with fistula ICD 10: K51.913; Ulcerative colitis (UC) is a longterm condition that results in inflammation and ulcers of the colon and rectum. The primary
symptoms of active disease are abdominal pain and diarrhea mixed with blood. Weight loss,
fever, and anemia may also occur. Often, symptoms come on slowly and can range from mild to
severe. Symptoms typically occur intermittently with periods of no symptoms between flares.
Complications may include megacolon, inflammation of the eye, joints, or liver, and colon
cancer. The cause of UC is unknown. Theories involve immune system dysfunction, genetics,
changes in the normal gut bacteria, and environmental factors. [Sohn, N; 2017] Rates tend to be
higher in the developed world with some proposing this to be the result of less exposure to
intestinal infections, or to a Western diet and lifestyle.
Plan:
Medications:
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Externally applied Rectiv 0.4 % (crème) 2 times per day each 12 hrs., to help increase blood flow
to the fissure and promote healing and to help relax the anal sphincter.
Lifestyle and home remedies
Several lifestyle changes may help relieve discomfort and promote healing of an anal fissure, as
well as prevent recurrences:
Add fiber to your diet. Eating about 25 to 30 grams of fiber a day can help keep stools soft and
improve fissure healing. Fiber-rich foods include fruits, vegetables, nuts and whole grains. You
also can take a fiber supplement. Adding fiber may cause gas and bloating, so increase your
intake gradually.
Drink adequate fluids. Fluids help prevent constipation.
Avoid straining during bowel movements. Straining creates pressure, which can open a healing
tear or cause a new tear.
Educated on the importance of compliance with plan of care
Advice patient to call the office if symptoms get worst
Patient agreed and verbalized understanding
Follow up / referrals
Follow up with provider in 2 weeks.
References:
1-Sadovsky, R. (1 April 2015). “Diagnosis and management of patients with anal fissures – Tips
from Other Journals”. American Family Physician. 67 (7): 1608.
1498-20200217-001.
2-Gupta PJ (2014). “Treatment of fissure in ano- revisited”. Afr Health Sci. 4: 58–62. PMC
2141661. PMID 15126193.
3-Sohn, N; Weinstein, M.A. (2017). “Anal dilatation for anal fissures”. Seminars in Colon and
Rectal Surgery. 8: 17–23.
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