PATIENT: MILLER, JUDITH ACCOUNT/EHR #: MILLJU001 Admitting Diagnosis: Gastrointestinal…

PATIENT: MILLER, JUDITH ACCOUNT/EHR #: MILLJU001 Admitting Diagnosis: Gastrointestinal hemorrhage HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old white female who presents with maroon stools. The patient noticed several episodes of maroon stools with clot yesterday. She called on the phone and was told to go to the emergency room (ER). The patient did not go to the ER and instead came to the office. There, she was noted to have normal vital signs and maroon stools in the rectal vault. The patient is now admitted for further evaluation. PAST MEDICAL HISTORY: The patient denies any previous history of gastrointestinal bleeding. She does have a history of arthritis and has been on Daypro. ALLERGIES: Bactrim SOCIAL HISTORY: Negative for smoking or drinking FAMILY HISTORY: Noncontributory REVIEW OF SYSTEMS: Notable for marked anxiety PHYSICAL EXAMINATION GENERAL: This is a well-developed, well-nourished, white female who is markedly anxious. VITAL SIGNS: Pulse 80, BP 130/70 HEENT: Conjunctivae pink. Sclerae anicteric. NECK: Without jugular venous distention LUNGS: Clear HEART: Regular rhythm ABDOMEN: Bowel sounds present, nontender, no rebound or guarding. NO masses or organomegaly. EXTREMITIES: No cyanosis, clubbing, or edema RECTAL: Exam revealed maroon stools. IMPRESSION: Gastrointestinal bleeding, etiology to be determined Anxiety Allergy to Bactrim SUGGESTIONS: Follow vital signs closely Colonoscopy Gastroscopy if colonoscopy is negative Transfuse prn