Multiple sinus with pus discharge on both buttocks of a male patient(case 2)

 July 5 , 2022  

General medicine blog 

Hi , I Ebrahim Badshah , a 3rd semester student.  This is an online elog book to discuss our patients health data after taking his consent. This also reflects my patient centered online learning portfolio.

The patient’s consent was taken prior to history taking and examination of his condition.

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan. 

CHIEF COMPLAINT:

A 46 year old male with pus discharge from abscess in perianal region , multiple sinuses in perianal region present.

Male patient who is an agriculture worker by occupation , resident of Coochbehar,West Bengal came to the OPD 2 days ago 

HISTORY OF PRESENT ILLNESS:

The patient was apparently asymptomatic 16 years ago . Then he developed a swelling(abscess) in the perianal. region associated with pain for which he went to the hospital and was treated conservatively with medication and the abscess was treated . After 2 months he again developed abscess in the same region for which he went to the hospital and had undergo a surgery(drainage of abscess).

After the surgery , he was asymptomatic for about 5 years then he develop_ed abscess on the surgical site . He was again treated conservatively and was advised Sitz bath for which he was on about 10 years . Later 6 months back he went to the same platform and was advised for MRI (MR Fistulogram) in which he was found to have a fistula seen in both sides of anal canal . The patient was referred to the surgery department for further consultation.

The patient has been referred to surgery department 

PAST HISTORY : 

N/K/C/O  DM, HTN, TB, Epilepsy , Asthma. 

PERSONAL HISTORY :

The patient smokes cigarettes since 25 years and is an alcoholic

Normal diet 

Inadequate sleep

Pain during defecation due to pus discharge 

Burning sensation during micturition due to medicines 

PHYSICAL EXAMINATION:

Patient is conscious and coherent

pallor ++

No icterus

No clubbing 

No pedal oedema 

No lymphadenopathy 

Malnourished/thin 

No cyanosis

VITALS:

Temperature:Afebrile 

BP:100/70 mm Hg

HR:80/min

RR:18/min

SpO2:

GRBS:119 mg/dL 

FAMILY HISTORY:

 None

ALLERGY HISTORY:

None

CLINICAL INVESTIGATIONS :

S1 and S2 sounds heard , no murmurs present .

RS:BAE positive

PA:Soft, non-tender

CNS:NAD

Montox test done results awaited