Progress Note Template: Hemorrhoids, Response to previous treatments (over-the-counter medications, home remedies)
Date:
Patient:
MRN:
Clincian: (Primary Care Physician, Gastroenterologist, Colorectal Surgeon)
Reason for Visit:
Follow-up for hemorrhoids
Evaluation of symptoms and response to treatment
Rectal examination (if indicated)
Discussion of treatment options and potential next steps
History of Present Illness:
Briefly describe the patient’s current status:
Severity and frequency of symptoms (bleeding, pain, prolapse, itching)
Duration of symptoms
Any aggravating factors (straining, constipation, heavy lifting)
Response to previous treatments (over-the-counter medications, home remedies)
Past Medical History:
Underlying medical conditions (chronic constipation, pregnancy)
Previous surgeries (rectal surgery may increase risk)
Family History:
Family history of hemorrhoids (may suggest increased risk)
Social History:
Diet (low fiber intake can contribute to constipation)
Physical activity level
Physical Exam:
Vital Signs: Normal vital signs are expected unless complications arise (bleeding).
Rectal examination (if indicated):
Assess for hemorrhoid grade (internal, external, prolapsed) and presence of thrombosis (blood clot).
Consider mentioning digital rectal exam findings if performed (normal rectal tone, stool consistency).
Labs:
Routine laboratory tests are not typically needed for hemorrhoids.
Consider mentioning a stool guaiac test if bleeding is severe to rule out other causes.
Imaging:
Imaging studies are not usually necessary for diagnosis of hemorrhoids.
Consider mentioning anoscopy or sigmoidoscopy if there is concern for a different diagnosis or if internal hemorrhoids need evaluation.
Assessment:
Summarize the diagnosis of hemorrhoids based on symptoms and physical exam findings (if performed).
Classify the hemorrhoid grade (internal, external, prolapsed) based on severity.
Plan:
Outline the treatment plan based on the severity of symptoms and hemorrhoid grade:
Conservative measures:
Increased dietary fiber intake
Stool softeners or laxatives to avoid straining
Sitz baths (warm water soaks) for pain relief
Over-the-counter topical creams or suppositories for pain and irritation
Minimally invasive procedures (for grade I or II hemorrhoids):
Rubber band ligation: Interrupts blood supply to shrink hemorrhoids.
Sclerotherapy: Injection of medication to shrink hemorrhoids.
Infrared coagulation: Uses heat to shrink hemorrhoids.
Surgical intervention (for severe or non-responsive cases):
Hemorrhoidectomy: Surgical removal of hemorrhoids.
Stapler hemorrhoidectomy: Minimally invasive procedure using a stapler to remove hemorrhoidal tissue.
Discuss potential risks and benefits of each treatment option with the patient.
Education:
Document any education provided to the patient regarding:
The nature of hemorrhoids and potential causes
Lifestyle modifications to prevent future episodes (diet, exercise, avoiding straining)
Proper wiping technique to minimize irritation
The importance of seeking medical attention for severe bleeding, prolapse, or uncontrolled pain
The details of the chosen treatment plan and potential side effects
Notes:
Include any additional relevant information not covered above, such as the patient’s understanding of the diagnosis and treatment plan, and any concerns they may have about pain management, treatment options, or potential complications.
Consider the impact of hemorrhoids on daily activities and offer reassurance or referral for support services if needed.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a physician or gastroenterologist for diagnosis, treatment recommendations, and prognosis.