Anal Pain

HISTORY:

Anal pain for ‍ ‍hoursdays

Onset: ‍gradualsudden ‍after bowel movement

Severity: ‍mildmoderatesevere, ‍012345678910 / 10

Type: ‍dullaching

Pattern: ‍constantintermittent

Worsening factors: ‍none

Treatments tried: ‍none, ‍effectiveineffective

‍rectal bleeding, ‍oncetwice ‍, ‍bright reddark red, ‍withwithout clots

‍lump

‍redness

‍discharge

‍itching

‍swelling

‍difficulty passing stools

‍constipation

‍diarrhea, ‍ episodes ‍per day, ‍

‍abdominal pain, ‍diffuse, ‍dull, ‍mild

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Anorectal: DRE ‍normal, prostate ‍normal, anus ‍normal



ASSESSMENT:

‍Anal fissure ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍CRP

- Stool culture

- Rectal swab for chlamydia and gonorrhea

- Colonoscopy

- CT scan of abdomen and pelvis

- ‍Analgesics

- ‍Topical treatments

- ‍Stool softeners

- Incision and drainage of abscess

- Sitz baths

- Increase fluid intake

- Increase dietary fiber

- Referral to gastroenterologist

- Referral to general surgeon

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen, if new symptoms develop such as weight loss or blood in stools, or if symptoms do not improve with treatment