:fissure in ano

-1
y old lady, k/c/o RA, SLE, ILD, Osteoporosis and Osteomyelitis (lt. upper 56
humerus)
-----------:P/C
===
Bleeding pr for 1 week
:HOPI
====
Pt. was in her USOH 1 week back when she started bleeding p/r whenever she
went to defaecate. She has h/o on and off constipation for about 6 months and
chronically suffers from low grade fever and drenching sweats as well. the
bleeding comes with the stool and splashes in the pain and continues for some
time drop by drop thereafter. It comes with normal stool as well. Pt. is anorexic w/
.nausea and low appetite also
No other significant systemic complaint
:Drug and Allergy Hx
=============
.she is allergic to penicillin, cephalosporins, clindamycin and sulpha drugs
currently she is on diclofenac 50 tid, tramadol 50 bid and co-codamol prn w/
calcium, vit. D supplements and calcitonin nasal spray 1 puff OD
:O/E
===
VS wnl
+Pallor
:Systemic exam
Chest: nvb, coarse crepts b/l d/t ILD, equal b/l air entry
CVS: S1+S2+0
+P/a: Soft, non-tender, BS
Local: 2 fissures ant. and post. at the anus w/ a small growth (?3rd degree
haemorrhoid) at 6'o'clock position..pr not possible d/t pinful fissures
:Impression
========
Anal fissures w/ 3rd degree haemorrhoids
:PLAN
====
Pt. is to be examined under anaesthesiacbc, coag, ue, ECGAdmit to 4 yellow ward:Post op
:Diet
Diet as tolerated or full diet
:Activity

Activity as tolerated
:Vital signs
Routine
:I.V. fluids
maintenance 100 ml d/s/hr
:Drugs
morphin 4 mg/6hrs prn, paracetamol iv 1 gm /6hrs
:Special orders
worm sitz path morning time
y old lady, k/c/o RA, SLE, ILD, Osteoporosis and Osteomyelitis (lt. upper 56
humerus)
-----------:P/C
===
Bleeding pr for 1 week
:HOPI
====
Pt. was in her USOH 1 week back when she started bleeding p/r whenever she
went to defaecate. She has h/o on and off constipation for about 6 months and
chronically suffers from low grade fever and drenching sweats as well. the
bleeding comes with the stool and splashes in the pain and continues for some
time drop by drop thereafter. It comes with normal stool as well. Pt. is anorexic w/
.nausea and low appetite also
No other significant systemic complaint
:Drug and Allergy Hx
=============
.she is allergic to penicillin, cephalosporins, clindamycin and sulpha drugs
currently she is on diclofenac 50 tid, tramadol 50 bid and co-codamol prn w/
calcium, vit. D supplements and calcitonin nasal spray 1 puff OD
:O/E
===
VS wnl
+Pallor
:Systemic exam
Chest: nvb, coarse crepts b/l d/t ILD, equal b/l air entry
CVS: S1+S2+0
+P/a: Soft, non-tender, BS
Local: 2 fissures ant. and post. at the anus w/ a small growth (?3rd degree
haemorrhoid) at 6'o'clock position..pr not possible d/t pinful fissures
:Impression
========
Anal fissures w/ 3rd degree haemorrhoids
:Labs
===

Urine dipstick: normal findings

CBC: microcytic hypochromic anemia of Hb 9, Neu 6.7
Coagulation profile: TT 23.3
U&E: Na 129, creatinine 103, urea 12.3, -2 anion gap
:PLAN
====
Pt. is to be examined under anaesthesiacbc, coag, ue, ECGAdmit to 4 yellow ward:TREATMENT AND PROGRESS DURING ADMISSION
=================================
She was hydrated, kept npo and underwent EUA with left lateral anal
sphincterotomy under GA in Lithotomy position
:Findings were
---------------partially healed anterior fissure in ano with small skin tag (12 oclock ) almost healed posterior fissure in ano (6 oclock) very small (few mm) perianal haematomas one at at 5 and other at 7 oclock .position
proctoscopy was normal.sigmoidoscopy attempted but the rectum was full of fecal matter so abandonedgelonet was put in place and dressing donePost-procedure pt. was given morphine 4mg s/c and hydrated..She recovered
well..ambulated in the morning voided urine normally and tolerated oral feeding
well also.She did not pass stool though.The dressing at wound site remained
dry.Apart from her severe joint pains, she did not experience significant pain at
.the surgical site at all
She was given a sitz bath in the afternoon, when dressing was removed and dsnt
.appear to be soaked-there was no bleeding or d/c
:DISCHARGE ADVICE AND PLAN
=====================
.Pt. comfortable and not much pain at wound site
So (as d/w dr.muayyad and dr.syed ali) she is for d/c now on analgesia, stool
softener (lactulose 15ml hs) and fybogel (to be taken with a lot of water 2 days
later) and xyloproct gel for local application, with advice to drink plenty of fluids,
.take sitz bath and not to delay bowel movement or strain during it
.Also to report to AnE sos, esp. if the perianal haematomas enlarge/burst