General medicine case 9

December 22, 2021

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Date of admission: 17-12-2021

A 28 year old male patient came to the casualty with a chief complaint of bleeding per rectum   and pain on defecation since 2 months  and  complaints of itching all over the body since 2 months 

HISTORY OF PRESENT ILLNESS:

Patient was apparantly asymptomatic 15 years ago, then he developed pain and difficulty on defecation and bleeding per rectum. Whenever he had pain & bleeding during defecation he used to take OTC medication and the pain used to get subsided .

In 2016 patient visited to  local hospital and got diagnosed with internal and external haemorrhoids for which he got treated with injection ( sclerotherapy) . He had no complaints for 1 year after the Sclerotherapy treatment , later the patient had developed  similar problems ie., pain & difficulty on defecation and bleeding per rectum then he again visited a local doctor and  started homeopathy medication for haemorrhoids.

History of pain and bleeding per rectum since 2 months 

History of itching all over the body since 2 months, multiple erythematous/ hyperpigmented papules noticed over the abdomen, web spaces, both forearms, arms, thighs, axilla 

PAST HISTORY:

patient is not a known case of hypertension , Diabetes mellitus , Asthama, Epilepsy, TB 

PERSONAL HISTORY:

Diet - Mixed 

Appetite - decreased 

Bowel and Bladder movements - difficulty on defecation (constipation), bladder movements are normal 

Patient is a daily smoker, he smokes 10-15 cigarettes or beedi's per day since 15 years

Consumes alcohol twice a week since 13 years and now he drinks occasionally since 1 year 

No known allergies

FAMILY HISTORY:

History of similar complaints in family 

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative

No icterus

No cyanosis

No clubbing

No Lymphadenopathy 

VITALS:

Temp - 98.7F

BP - 120/80 mmHg

PR - 83bpm

DIFFERENTIAL DIAGNOSIS:

Anal cancer, anal fissures, anal fistulae 

Atopic dermatitis

PROVISIONAL DIAGNOSIS:

Haemorrhoids

Scabies 

TREATMENT:

PERMITHRIN 5% LOTION 

TAB. ATARAX 25mg

CAP. OXERUTE CD

SMUTH - L liquid 30 ml 

TAB. MVT