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VELASQUEZ, CRISTINA, E.

2012 MED III PEDRO

` DR.

FEB 10, SAN

GENERAL DATA M.C, 33/M right handed, Catholic, presently residing at Antipolo Rizal . Admitted at QMMC February 1, 2012. CHIEF COMPLAINT: bleeding HISTORY OF PRESENT ILLNESS: 11 years prior to admission, the patient noticed that his stool is preceeded by bleeding about 3ml which happened intermittently. The stool is fromed and not mixed with blood and no pain was noted. He felt a 1cm mass protruding from his anus after defecation and was spontaneously reduced. No medication or consult was done. 4 years prior to admission, the patient still presented with the above symptoms, but the bleeding was increased in severity and was aassociated with fever, He was confined to UST hospital and was diagnosed with Dengue hemorrhagic fever. He was transfused with 10 bags fresh frozen plasma and was discharge after a week. 1 year prior to admission, the patient experienced 2week of bleeding coming from the anal area associated with chills and pallor. He was rushed to Amang Rodriguez Medical Center and was diagnosed with Gastritis. He was given tranicsamic acid and the symptoms were relieved. 2 months prior to admission, the patient was still bleeding exacerbated by straining. There was a changed in the caliber of stool with ribbon like character. The mass that is protruding in the anal area had to be manually reduced. He took tranicsamic acid and the symptoms weere relieved. 2weeks prior to admission, the patient still had the above symptoms. He took tranicsamic acid but was not relieved. The protruding mass is not reducible. The above mention symptoms still persisted so he dedicided to seek consult. PAST MEDICAL HISTORY: The patient wass diagnosed with fatty liver. FAMILY HISTORY:

Father- has hypertension and asthma Mother- has diabetes mellitus type2

PERSONAL & SOCIAL HISTORY: The patient is married, works as a jeepney driver. He is fond of eating fatty foods and kilawin. REVIEW OF SYSTEMS: (-) headache (-) fever (-) rash & pruritus (-) chest pain (-) diarrhea (+) constipation (-) weight lost (-) blurring of vision

PHYSICAL EXAMINATION: The patient is conscious, coherent, not in cardirespiratory distress. Vital Signs: Temp.: 35.4 C BP: 110/70 mmHg RR: 22 breadths/min. HEENT: The patients skull is normocephalic, no signs of any previous head trauma, pink conjunctiva, anicteric sclera, (+) ROR, (+) direct and consensual light reflexes, non-hyperemic, pink oral mucosa, uvula and tongue is in midline, no dentures, and no lymphadenopathies, LUNGS: No chest deformity, equal chest expansion and tactile fremitus, Normal breath sounds, no wheezes and crackles. CHEST: Adynamic precordium, distinct heart sounds, good S1 & s2, no murmurs. ABDOMEN: The abdomen is flat, (+) scars on the right upper quadrant, got from a dog bite, normoactive bowel sounds, (-) direct and rebound tenderness, (-) Rovsings sign (-) Psoas and Obturator sign DRE: (-) skin tag, good sphincter tone, intact rectal vault, (+) palpable mass on the right anterolateral portion at the anal vault, soft non tender, prostate not enlarge, no blood or feces upon withdrawal. HR: 64 beats/min. Height: 57

The patients DTR is grade 2+ Muscle strength of 5/5 Intact cranial nerves PRIMARY IMPRESSION: Grade III INTERNAL HEMORRHOIDS Internal hemorrhoids arise from the superior hemorrhoidal cushion. Their three primary locations (left lateral, right anterior, and right posterior) correspond to the end branches of the middle and superior hemorrhoidal veins. The overlying mucosa is rectal, and innervation is visceral. Vascular structures contained in hemorrhoidal complexes prolapse into the anal canal as a result of engorgement and straining. We consider this as our primary diagnosis because of the painless bleeding not mixed with stool and the protruding mass in the anal area upon straining. Risk factors such as male gender, high fat and low fiber diet also contribute to the diagnosis. ClassificationInternal hemorrhoids are graded according to the degree to which they prolapse from the anal canal: Grade I hemorrhoids are visualized on anoscopy and may bulge into the lumen but do not extend below the dentate line. Grade II hemorrhoids prolapse out of the anal canal with defecation or with straining but reduce spontaneously. Grade III hemorrhoids prolapse out of the anal canal with defecation or straining, and require the patient to reduce them into their normal position. Grade IV hemorrhoids are irreducible and may strangulate

LABS/WORKUPS:/DIAGNOSIS rarely indicated, except to assess degree of anemia in significant bleeding (CBC) Proctosigmoidoscopy- evaluate the lining of the distal sigmoid colon, rectum, and anal canal To aid diagnosis of inflammatory, infectious, and ulcerative bowel disease.

To diagnose malignant and benign neoplasms

To detect hemorrhoids, hypertrophic anal papilla, polyps, fissures, fistulas, and abscesses in the rectum and anal canal

MANAGEMENT/TREATMENT PLAN: SURGERY Continued symptoms despite conservative or minimally invasive measures usually requires surgical intervention. In addition, surgery is the initial treatment of choice in patients with symptomatic grade IV hemorrhoids or those who have strangulated internal hemorrhoids. It may also be required for symptomatic grade III hemorrhoids and in patients who present with thrombosed hemorrhoids.. Techniques for the operative treatment of hemorrhoids include: These procedures usually require general or spinal anesthesia. However, selected patients may tolerate the procedure with sedation and a local anesthetic. 1) Closed hemorrhoidectomyClosed hemorrhoidectomy, or a modification of the technique, is the most common surgical procedure performed for internal hemorrhoids. For the standard closed hemorrhoidectomy, an elliptical incision is made starting on the external hemorrhoidal tissue and extending proximally across the dentate line to the superior extent of the hemorrhoidal column. Care is taken to make the ellipse relatively narrow, and to remove only the redundant anoderm and hemorrhoidal tissue. The defect is closed with a continuous absorbable suture. Usually three hemorrhoidal columns are treated. This technique is successful in 95 percent of cases and has a low rate of wound infection. 2) Open hemorrhoidectomyTo reduce the risk of infection, some surgeons advocate excision and ligation without mucosal closure. The semi-open technique was associated with more rapid healing and a lower incidence of postoperative complications. 3) Stapled hemorrhoidectomy (stapled hemorrhoidopexy)An intraluminal circular stapling device has been developed as an alternative to conventional surgical hemorrhoidectomy. The device excises a circumferential column of mucosa and submucosa from the upper anal canal, thus reducing the hemorrhoids back into the anal canal and fixing them in position. It also interrupts part of the hemorrhoidal blood supply thereby decreasing vascularity. It is not appropriate for treatment of external hemorrhoids.

After surgery, observe patients regulary until they are healed and asymptomatic. Stool softeners, fiber supplements and warm sitz bath may help post operative discomfort. DIFFERENTIAL DIAGNOSES: RECTAL PROLAPSE- (procidentia) is a circumferential, full thickness protrusion of part of the rectal wall through the anal orifice. We ruled it in because of the bleeding, and the masss protruding upon straining, however as the name implies, the whole rectal valult does not protrude and there is no anal pain PROCTITIS- Infections acquired by anal/rectal inoculation(Neisseria,Chlamydia, HSV, Treponema). We ruled it in because of the rectal bleeding. However the bleeding is not the main presenting symptom. Tenesmus, rectal pain, mucus discharge, rectal and perinal ulcers and inguinal lympadenopathy are some of the most common presentation of proctitis which is not present in our patient POLYPOSIS COLI- depending on the involved anatomic location, polyps may become large thaat can cause obstruction resulting to symptoms like rectal bleeding, change in stool caliber, hematochezia. And is usually malignant in potential. In our patient, there is no change in bowel habit, no anemia, weight loss.

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