A 29 yr old male patient jewellery maker by occupation presented to medicine OPD 4 days back with chief complaints of

 

A 29 yr old male patient jewellery maker by occupation presented to medicine OPD 4 days back with chief complaints of 

Constipation since 1 month 

Bleeding per rectum since 1 month

HOPI: 

Since 1 month pt is having difficulty in passing stools .it was associated with passing of blood in stools every time he tried to pass stools.Associated with severe pain and itching around Anus and a feeling of incomplete evacuation of bowel . No abdominal pain. 

Patient had 2 episodes of vomitings 10 days nd 3 days prior coming to Hyderabad which were associated with retrosternal pain,burning sensation in epigastrium and few drops of blood.

Past history: not a known case of diabetes,HTN,asthma,epilepsy,thyroid disorders,ckd,cad 

PERSONAL HISTORY:

Diet- mixed 

Appetite-normal

Bowel and bladder- regular 

Sleep-adequate 

Addictions- smoking since 15 yrs 

Alcohol since 10 yrs stopped 2 months back

EXTENDED HISTORY:

In 2006, gastric problems increased (suspected etiology new kind of food, used to eat spicy foods, work very late night). He felt bloated, tenesmus, hard stool(3-4 times/day), constipation, flatulence, abd. pain. Occasionally, few drops of raw blood used to come out with stool (2-3 days continuously, then again with a gap of 1-3 months). Had medicine from a local pharmacy, which decreased frequency of flareups of bleeding pr. Pt. did not seek anymore treatment because of shyness to discuss such issues and during flareups would take medicine from pharmacy.

In 2015-16, frequency of bleeding started increasing with feeling of splinter hemorrhagic pain/ burning sensation while passing of hard stool. Described the stool to be of very hard consistency at the beginning of defaecation and of dark color initially followed by softer stool of normal color. Went to Dr. who diagnosed it to be hemorrhoids and performed sclerotherapy. Treatment continued for one month. After which for one yr no problem. 

In 2017, went to Dubai, to work in a jewelry shop. After 1-2 months again bleeding started. Used to happen for 1-2 days (a few drops of blood), then again after a gap of 2-3 months. For 1.5 yrs, while in Dubai no treatment was done. 

Started homeopathy treatment in 2018, and continued till 2021. Gastric problem resolved. But hemorrhoids still persisted. 

1.5 yrs ago he went to AP, to work as construction labor. He noticed that bathing in cold water leads to itchiness and papular rashes all over body which would go away in 2-3 hrs after bathing. And since childhood during summer months used to have lot of prickly heat. Recently, happening more often, would go away when he works in AC room.

In 2021 Dec, went to Hyderabad for treatment of hemorrhoids. Also, c/o itchiness and papula with peeling of skin which resolved with ointment and medicine for allergy. Stayed in hospital for 11 days. Was prescribed medications. After returning home took 1 month complete rest. No more bleeding pr.

Then in Feb 2022, came to Hyderabad as an advocate for another patient. Returned home after staying in Hyderabad for 2-3 days. Pt suspect due to travelling for long hours in train, not bathing, eating spicy food, skipping proper meals resulted in recurrence in hemorraghic bleeding after he returned home. Stayed at home for 2-3 months, took complete rest and took all the medices prescribed. 

2-3 months later went to Kerala for work. After 1 month staying there, bleeding per rectum daily with burning sensation while passing stool. Came to Hyderabad, where colonoscopy and endoscopy was done. 

Rectal biopsy report:

FAMILY HISTORY: 

Father - Age 60 yrs. k/c/o DM since past 4-5 yrs, high cholesterol, HTN, SOB and heart ailments. Addiction - paan, nutmeg

Mother - k/c/o HTN, cholesterol and gastric issues(flatulence, bloating, burps). Osteoarthritis. Pain increases during winter season. Cannot walk for long

Elder brother - At young age had hemorrhoids Sx. Complete recovery. k/c/o Dm, obesity (wt 112kg)

GENERAL EXAMINATION 

Patient is conscious, coherent and cooperative 

Well oriented to time ,place, person

Moderately built and nourished 

Pallor-no

Icterus-no

Cyanosis-no

Clubbing-no

Lymphadenopathy -no

Edema-No

VITALS

BP 130/80 mmhg

PR 92bpm

RR 18cpm

TEMP afebrile

SYSTEMIC EXAMINATION 

RS : NVBS ,BAE+, crepts 

CVS: S1 S2 +

CNS: NFD

PA: soft, non tender

PROVISIONAL DIAGNOSIS: Grade 3 external hemorrhoids along with

scabies 

IBD 

reflux esophagitis grade A, 

rectal ulcer - ?SRUS, 

int. hemorrhoids with RCS 

TREATMENT:

Tab. NEXPRO 40mg/BD 

Syrup. SUCRALFATE 10ml TID after food 

Syrup. CREMAFFIN 15ml

ANOBLISS cream 2 times a day

Plenty of fluids 

Pt was referred to surgery department and is planned for a surgery .