CASE HISTORY-9

21 December 2021 

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Date of admission: 17-12-2021

A 28 year old male patient who is a jewellery worker by occupation presented 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 

Daily routine of the patient before illness: Patient is a jewellery worker and sits for a prolonged time in a day and eats breakfast lunch dinner in abnormal timings and experienced constipation and he is a chronic smoker and alcoholic.

Daily routine after illness: Patient routine was the same after illness he reduced alcohol consumption. 

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 medication and the pain used to subside.

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 he 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 which was a temporary relief.

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 

Sleep- adequate

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

Patient is a daily smoker,smokes 10-15 cigerettes 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. His younger brother had undergone hemorrhoid surgery.

GENERAL EXAMINATION:

Patient is conscious, coherent, cooperative

Not pallor 

No icterus

No cyanosis

No clubbing

No Lymphadenopathy 

VITALS:

PR-83bpm

RR-16cpm 

Temp: 98.7°F

BP - 110/80 mmHg

DIFFERENTIAL DIAGNOSIS: anal fissures, anal fistulae,anal cancer

Atopic dermatitis, contact dermatitis

PROVISIONAL DIAGNOSIS: 

Haemorrhoids 

Scabies 

TREATMENT:

Intake of fibrous foods, restriction of fat food 

PERMITHRIN 5% LOTION 

TAB. ATARAX 25mg

CAP. OXERUTE CD

SMUTH - L liquid 30 ml 

TAB. MVT