Anal Pain

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of anal pain

Onset was ‍gradualsudden ‍after bowel movement

Rated at ‍012345678910 / 10 ‍

Described as ‍dullaching

Pattern ‍persistentintermittent

Worsening factors: ‍none

Alleviating factors: ‍none, ‍effectiveineffective



Associated symptoms: *Try using right-click for negatives*

‍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



Contributing factors:

‍anal sex

‍use of irritants such as soaps

‍poor hygiene

‍obesity

‍pregnancy

no history of: ‍hemorrhoids, ‍anal fissures, ‍anal abscess, ‍inflammatory bowel disease, ‍colon or rectal cancer, ‍prostatitis

no use of: ‍laxatives, ‍stool softeners





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

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

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Anorectal: DRE ‍normal, prostate ‍normal, ‍blood, ‍mass, anus ‍

Pelvic: external genitalia ‍normal, vagina ‍normal, cervix ‍normal, uterus ‍normal, adnexa ‍normal, ‍cervical motion tenderness

Genital: penis ‍normal, testes and epididymis ‍normal, ‍inguinal hernia





ASSESSMENT:

‍Anal fissure ‍likelysuspectedpossible

DDx: anal fissure, thrombosed hemorrhoid, proctitis, perianal abscess, fistula-in-ano, rectal prolapse, pilonidal cyst, rectal ulcer, gonorrhea, perianal HSV, anal warts, anal cancer, rectal carcinoma, pruritus ani, cryptitis, proctalgia fugax, chronic proctalgia, levator ani syndrome





PLAN:

Investigations:

- Blood work: ‍CBC, ‍CRP

- Stool culture

- Rectal swab for chlamydia and gonorrhea

- Colonoscopy

- CT scan of abdomen and pelvis

Treatments:

- ‍Analgesics

- ‍Topical treatments

- ‍Stool softeners

- Incision and drainage of abscess

- Sitz baths

- Increase fluid intake

- Increase dietary fiber

Further care:

- 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