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Rectal Pain: 1. Chief Complaint 2. HPI

The patient presented with rectal pain as the chief complaint. Their medical history revealed potential relevant conditions like hemorrhoids, inflammatory bowel disease, and anal abscesses. A physical exam and differential diagnosis were needed to determine the cause of the pain, which could be from various conditions like hemorrhoids, muscle spasms, or inflammation. Tests and treatments may include procedures, medications, and lifestyle changes to relieve the pain.

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drnareshkumar3281
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243 views4 pages

Rectal Pain: 1. Chief Complaint 2. HPI

The patient presented with rectal pain as the chief complaint. Their medical history revealed potential relevant conditions like hemorrhoids, inflammatory bowel disease, and anal abscesses. A physical exam and differential diagnosis were needed to determine the cause of the pain, which could be from various conditions like hemorrhoids, muscle spasms, or inflammation. Tests and treatments may include procedures, medications, and lifestyle changes to relieve the pain.

Uploaded by

drnareshkumar3281
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd

RECTAL PAIN

1. CHIEF COMPLAINT
•Rectal Pain
2. HPI
1. Concern
2. Onset
Sudden
Gradual
3. Duration
•Recent
•A few days
•Many days
•A few weeks
•Many weeks
•A few months
•Many months
•A few years
•Many years
•Recurrent
•n/a
4. Severity
•Mild
•Moderate
•Severe
•Normal
•Increased
•Decreased
•Stable
•No significant change from prior visit
5. Frequancy
6. Location:
7. Aggravated by-
•Sitting
•Bowel movement

8. Relieved by
•Walking
9. Associated Symptoms
10. Pertinent Negatives
11. Notes
3. ROS
4. ASSOCIATED SYMPTOMS
•Rectal bleeding
•Rectal discharge
•Burning
•Itching

5. HISTORY
•FAMILY HISTORY
o Diabetes
o Inflammatory bowel syndrome

•SOCIAL HISTORY
•PASTMEDICAL HISTORY
o Hemorrhoids
o Proctalgia fugax
o Levator ani syndrome
o Cancer
o Anorectal abscesses
o Proctitis
o Inflammatory bowel disease
o Ulcerative colitis
o Crohn disease
o Rectal prolapse

•SURGICAL HISTORY
•CHRONIC CONDITIONS

6. ALLERGIES

7. PHYSICAL EXAMINATION

8. SPECIFIC DATA LIKE GRADING ETC

9. DIFFERENTIAL DIAGNOSIS
a. Hemorrhoids
b. Proctalgia fugax
c. Levator ani syndrome
d. Cancer
e. Anorectal abscesses
f. Proctitis
g. Inflammatory bowel disease
h. Ulcerative colitis
i. Crohn disease
j. Rectal prolapse

10.TESTS TO BE ORDERED
•CBP
•USG
•X-ray
•Sigmoidoscopy
•Colonoscopy
•Anoscopy

11.ASSESSMENT /PLAN
a. Rubber band ligation
b. Hemorrhoidolysis/Galvanic Electrotherapy
c. Sclerotherapy
d. Cryosurgery
e. Laser, infrared or BICAP coagulation
f. Hemorrhoidectomy
g. Stapled Hemorrhoidectomy
h. Enema

12.EDUCATION
•Sit in a tub of hot water
•Massage the levator ani muscles to relieve the muscle spasm.
•Eat a high-fiber diet and use stool softeners to make bowel
movements less painful.

13.MEDICATION
•Ibuprofen
•Naproxen
•Nupercainal
•Proctosedyl
•Benzocaine
•Benzyl alcohol 5% to 20%
•Dibucaine 0.25% to 1.0%
•Dyclonine 0.5% to 1.0%
•Lidocaine 2% to 5%
•Pramoxine 1.0%
•Tetracaine 0.5% to 5.0%
•Ephedrine sulfate 0.1% to 1.25%
•Epinephrine 0.005% to 0.01%
•Phenylephrine 0.25%
•Aluminum hydroxide gel
•Cocoa butter
•Glycerin
•Kaolin
•Lanolin
•Mineral oil
•White petrolatum
•Starch
•Zinc oxide or calamine
•Calamine 5% to 25%
•Zinc oxide 5% to 25%
•Witch hazel 10% to 50%
•Boric acid
•Hydrastis
•Phenol
•Benzalkonium chloride
•Cetylpyridinium chloride
•Benzethonium chloride
•Resorcinol
•Aluminum chlorhydroxy
•Allantoinate 0.2% to 2.0%
•Resorcinol 1% to 3%
•Menthol 0.1% to 1.0%
•Camphor 0.1% to 3%
•Juniper tar 1% to 5%

14.FOLLOW-UP

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