Scenario 2, Part 2 of 3

Office record from Florida medical center two years ago

"…states had severe hemorrhoids during her pregnancies…severe bout diarrhea ten years ago…produced damage to anus and rectum…had hemorrhoid surgery about 18 years ago…relieved large protruding hemorrhoids…since then, has had intermittent bouts of anal pain…some bleeding…has appointment to see proctologist…has had sigmoidoscopies which have been negative.

PE: some external hemorrhoidal tags…tender little fissure at three o'clock…rectal exam internally is normal. Impression: anal fissure…pain…bleeding. Advised follow through with surgical consultation…but she seems to think she probably will not."

Blood chemistry and cholesterol lab studies unremarkable. "RBC 4.5 [range 3.9-5.2], Hgb 13.8 [range 12-15.1], hematocrit 42.9 [range 35.0-46.0]."

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