TAYLOR, READER, & ASSOCIATES

A Complete Health Care Facility

975 CENTRAL AVENUE SOMEWHERE, FL 32811 407-555-4321

PATIENT:

WILLIAMS, CONRAD

ACCOUNT/EHR #:

WILLCO001

DATE:

06/21/18

Attending Physician:

Suzanne R. Taylor, MD

S: Pt is a 51-year-old male who I have not seen since his annual physical exam last September. He states that 5-6 weeks ago he noted some intermittent soft stool and decrease in the caliber of stools. He also noted some bleeding that discontinued four days ago. He denies any cramps or abdominal pain.

O: External examination of the anus revealed some external skin tags present in the left anterior position. Anal examination revealed an extremely tight anal sphincter. This was dilated manually to allow instrumentation with the anoscope, which was accomplished in a 360-degree orientation. There was some prominence of the crypts and some inflammation of the rectal mucosa, a portion of which was sent for biopsy. This was friable. In the left anterior position there was a fistula that was healing with some formation of a sentinel pile on the outside, which had been noticed on external examination.

A: Anal fissure, unusual position, nontraumatic

P: 1.Rule out inflammatory bowel disease with air contrast barium enema examination and reflux into terminal ileum.

2.Patient to return for sigmoidoscopy after BE.

_______________________________________________________________

Suzanne R. Taylor, MD

SRT/pwD: 06/21/18 09:50:16T: 06/25/18 12:55:01