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SEER Training Modules

Manipulative Procedures Example 1

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  • Rec. No.: 000019
  • Name: Ivan Block
  • Age: 65
  • Sex: Male
  • Race: White
  • Date: 03/31/91

Chief Complaint Bloody Stools Referred by Everett Hope, MD

  • Previous Proctoscopy: Yes
  • Date: 03/20/84
  • Findings: Negative
  • Previous Rectal Surgery: None

History

  1. Blood per Rectum Occas for 6 mo.
  2. Abdominal Colic None
  3. Appetite Recent loss
  4. Abscess _________
  5. Itching __________
  6. Weight Loss 10 lbs.
  1. Protrusion Intermittent
  2. Change in bowel habits: Diarrhea
  3. Draining fistula __________
  4. Rectal Pain__________
  5. Fever __________
  6. Constipation Alt. Const./diarrhea
  1. Diarrhea ______ Duration _______ Character of Stool-Ribbon-like
    Periodic for 6 mo. No of Stools ________ Blood ________
    Mucus __________ Cramps ___________
  2. Laboratory: Frei _____Serology_____ Ova & Parasites ________

Proctoscopy

  • Distance Scoped: 8 cm Interference ________________
  • Mucosa: Normal Red _____ Edmatous X Friable __________
  • Ulcerated ________Vascular Pattern _______Mucua _______
  • Pus ______ Blood X Granular ________ Glistering __________

Description of Other Pathology and Remarks:

  1. Digital-Hemorrhoids. Mass palpable posteriorly; feels fixed to sacrum; impinges on lumen
  2. Proctoscopy-Obstruction posteriorly @ 8 cm. Multiple Bx's taken. Could not pass either regular size or stricture scope past lesion

Examined by: Sid Procter, MD

Proctoscopy Report