General Medicine E log 1



July 5,2022 

A 46 year old male patient with multiple fistula in Anal perineum

Hi, we are Humera Firdous and Ebrahim Badshah  of 3rd semester. This an online E logbook 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.

CHIEF COMPLAINT:
A 46 year old male patient who is a farmer by occupation residing in Cooch Behar district of West Bengal came to the OPD with a complaint of recurrent pus discharge from the perianal region since 10 years.

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 undergone a surgery( Drainage of abscess).

After the surgery, he was asymptomatic for about 5 years then he developed abscess on the surgical site.He was again treated conservatively each time he developed the abscess in the past 10 years( for about 20 times) and was also advised sitz bath.Later 6 months back he went to the hospital with the same problem  and was advised an MRI ( MR fistulogram) in which he was found to have fistula seen in both sides of anal canal.As the problem was recurring frequently for the past 10 years and subsiding after conservative treatment the patient came to the OPD on 4 of July where he was examined and  was referred to the surgery department for further consultation.

PAST HISTORY:
The patient had undergone a surgery for drainage of abscess in the perianal region 15 years ago.
History of similar complaints in the past: Abscess associated with pain in the surgical site occurring frequently since the past 10 years( for about 20 times).
N/K/C/O DM,HTN,TB,Asthma,Epilepsy

PERSONAL HISTORY:
DIET:Mixed
APPETITE:Normal
SLEEP:Inadequate 
BOWEL:Regular
BLADDER:Burning Micturition due to usage of drugs
ADDICTIONS:
The patient is a chronic smoker who has been smoking 3 beedis per day since the past 25 years and has stopped smoking ever since he had been admitted to the hospital two days back.He consumes alcohol occasionally.

FAMILY HISTORY:
No significant family history

GENERAL EXAMINATION:
The patient is undernourished and thin built
Patient was concious,coherent and co-operative
Pallor ++
No icterus
No cyanosis
No clubbing of fingers
No lymphadenopathy
No oedema of feet











VITALS:
Temperature:Afebrile 
BP:100/70 mm Hg
HR:80/min
RR:18/min
SpO2:
GRBS:119 mg/dL 

SYSTEMIC EXAMINATION:
CVS: S1,S2 heard,No murmurs
RS:BAE positive
PA:Soft, non-tender
CNS:NAD






INVESTIGATIONS:

The tests ordered were Hemogram,Serum Creatinine,Blood Urea,ECG,Chest X-ray,MRI(fistulogram),USG(Abdomen),Mantoux test
The report of MRI( fistulogram)  is still awaited as of 7 of July, 2022
The results of Mantoux test is awaited.(Expected on 9 July,2022)
HEMOGRAM:

HEPATITIS-B:


HCV:


SERUM CREATININE:

RANDOM BLODD SUGAR:

BLOOD UREA:
HIV:
CHEST X-RAY
ECG:

USG(PERINEUM):




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