Thomas is a 58-year-old male with ASHD, DM type 2, HTN, and GERD who presents with c/o rectal bleeding. He states, "There was blood in the toilet after I had a bowel movement." He admits he was straining a lot to pass the stool

PMH: As noted, the patient has ASHD, DM type 2, which is well controlled with metformin and Byetta, HTN—controlled by Norvasc. He also takes omeprazole, Simvistatin, and Neurontin for diabetic neuropathy. He reports the ASHD is "stable at this time, according to my cardiologist."

Temp: 99 Pulse: 76 BP: 130/74 Blood sugar: 110

Physical Exam:

ENT—PERRLA, no PND

Neck: WNL—no lymphadenopathy

Cardiovascular—RRR, no JVD, no carotid bruits

Lungs—normal breath sounds; no rales or crackles

Abdomen —normal bowel sounds

Digital Rectal Exam—stool on glove was brown. No evidence of blood. Hemorrhoids were noted.

Fecal occult blood test was negative.

EKG—WNL

CBC—both H&H are within normal limits

I discussed my findings with the patient. Since the fecal occult blood test was negative, and the EKG and H&H are normal, I do not think he is bleeding internally. He has both internal and external hemorrhoids. What I believe happened is that one of the hemorrhoids "popped" as he was straining to defecate. I am discharging him home with instructions to return to the ED should he experience any additional rectal bleeding, or if he notes any blood in his stool. Otherwise, I would like him to follow up with Dr. Jason Kittridge at our GI clinic within the next week.

Impression: ASHD, Hemorrhoids, DM with neuropathy, GERD

What will be an ideal response?

Answer: Hemorrhoids NOS—K64.8
ASHD—I25.10
Type 2 diabetes mellitus with neuropathy—E11.40
GERD—K21.9