Patient: [Patient Name]
MRN: [Medical Record Number]
Date: [Date of Encounter]
Chief Complaint: Lower gastrointestinal (GI) bleeding (hematochezia – bright red rectal bleeding, melena – black tarry stools)
History of Present Illness:
Describe the onset, character, and frequency of the bleeding (e.g., painless, maroon-colored rectal bleeding for the past 2 days).
Inquire about the passage of clots or mucus in the stool.
Ask about associated symptoms that may suggest the location of the bleeding source (e.g., abdominal pain, cramping, tenesmus – urgency to defecate with minimal stool passage).
Mention any recent changes in bowel habits (diarrhea, constipation).
Past Medical History:
Include any relevant past medical history, such as:
Underlying GI conditions (diverticulosis, inflammatory bowel disease, peptic ulcer disease)
Previous episodes of GI bleeding
History of NSAID or anticoagulant use (both can increase bleeding risk)
Comorbidities that can worsen bleeding (e.g., liver disease, coagulopathies)
Medications:
List all current medications, including those that may increase bleeding risk (NSAIDs, anticoagulants).
Social History:
Inquire about alcohol and tobacco use (both can contribute to GI bleeding).
Family History:
Inquire about a family history of GI conditions (e.g., inflammatory bowel disease).
Physical Exam:
Vital signs: Include temperature, pulse rate, blood pressure (orthostatic hypotension may suggest significant blood loss).
General examination: Assess for signs of dehydration or shock (pale skin, cold extremities, altered mental status).
Abdominal exam: Palpate for abdominal tenderness, distention, or masses.
Rectal exam: Evaluate for hemorrhoids or other rectal pathology.
Laboratory Tests:
Complete blood count (CBC): Assess for anemia (low hemoglobin or hematocrit) suggestive of blood loss.
Coagulation studies (PT/PTT): Evaluate for any underlying bleeding disorders.
Electrolytes: Assess for electrolyte imbalances that can worsen bleeding or be a consequence of blood loss.
Occult blood testing: May be done on stool samples to detect hidden blood loss.
Imaging Studies (if performed):
Colonoscopy: The gold standard for diagnosing the source of lower GI bleeding, particularly for suspected colonic bleeding.
CT scan with angiography: May be used if colonoscopy is contraindicated or inconclusive, to localize the bleeding source.
Assessment:
Severity of bleeding: Describe the perceived severity of bleeding based on clinical presentation (amount of blood loss, hemodynamic stability).
Source of bleeding: State the suspected or confirmed source of lower GI bleeding based on history, physical exam, and investigations (e.g., diverticular bleeding, angiodysplasia).
Hemodynamic status: Assess the patient’s current hemodynamic stability and risk for complications.
Plan:
Resuscitation: This is the priority for patients with active bleeding and hemodynamic instability. This may involve:
Intravenous fluids to restore blood volume.
Blood transfusion if needed to correct anemia and improve oxygen-carrying capacity.
Identification of bleeding source: Perform appropriate diagnostic studies (colonoscopy, CT angiography) to identify the bleeding location.
Specific treatment for bleeding source: The specific treatment approach will depend on the identified source. This may include:
Endoscopic therapy (e.g., banding, injection) for bleeding peptic ulcers or hemorrhoids.
Angiography with embolization for bleeding from vascular malformations.
Surgical intervention for severe or uncontrolled bleeding.
Medications:
Discontinue medications that increase bleeding risk (NSAIDs, anticoagulants if possible).
Proton pump inhibitors (PPIs) may be used to reduce stomach acid and promote healing of peptic ulcers.
Follow-up:
Depending on the severity of bleeding and the underlying cause, the patient may require hospitalization for monitoring and management.
Schedule follow-up clinic visits to assess for recurrent bleeding and address any underlying GI conditions.
Consider referral to a gastroenterologist for ongoing management of chronic GI conditions.