a 29 years old male patient with hemorrhoids

29 yr old male with c/o constipation, bleeding pr and gastric problems 

July 31,2022

NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT 

PATIENT'S HISTORY: The patient is a 60-year-old housewife. In 2013, she had an episode of probable stroke followed by nausea, vomiting, diarrhea, weakness, fatigue with loss of appetite, and insomnia. Her legs felt numb. She lost sensation around neck. Had to be admitted to a nursing home. Diagnosis of hypocalcemia and hypokalemia was made. Got discharged after 5 days when k+ and Ca2+ lvl. returned to normal via i.v infusion. For 2 yrs she was fine. In 2015,  due to diarrhea and fatigue she got admitted to a Nursing home and stayed there for 7 days. Ca2+ and K+ lvl. was falling, so restored via i.v

PATIENT HISTORY: Pt is a 29 yr old male working in a jewelry making shop. At the age of 7yrs, he underwent an operation for inguinal scrotal hernia. Since childhood he suffers from gastric problems. When in class 3-4, tooth extraction done due to dental caries. Pt at that time loved to eat sweets and chocolates. At the age of 11 yrs, in 2006, went to kerala to work in a jewelry making shop. His gastric problems increased (suspected etiology new kind of food, used to eat spicy foods, work very late night). He felt bloated, tenesmus, hard stool(3-4 times/day), constipation, flatulence, abd. pain.  Occasionally, few drops of raw blood used to come out with stool (2-3 days continuously, then again with a gap of 1-3 months). Had medicine from a local pharmacy, which decreased frequency of flareups of bleeding pr. Pt. did not seek anymore treatment because of shyness to discuss such issues and during flareups would take medicine from pharmacy.

In 2014, had to extract a tooth due to caries and pain. Root canal done for another tooth 1-2 yrs later.

 In 2015-16, frequency of bleeding started increasing with feeling of splinter hemorrhagic pain/ burning sensation while passing of hard stool. Described the stool to be of very hard consistency at the beginning of defaecation and of dark color initially followed by softer stool of normal color. Went to Dr. who diagnosed it to be hemorrhoids and performed sclerotherapy. Treatment continued for one month. After which for one yr no problem. 

In 2017, went to Dubai, to work in a jewelry shop. After 1-2 months again bleeding started. Used to happen for 1-2 days (a few drops of blood), then again after a gap of 2-3 months. For 1.5 yrs, while in Dubai no treatment was done. 

Started homeopathy treatment in 2018, and continued till 2021. Gastric problem resolved. But hemorrhoids still persisted. 

1.5 yrs ago he went to AP, to work as construction labor. He noticed that bathing in cold water leads to itchiness and papular rashes all over body which would go away in 2-3 yrs after bathing. And since childhood during summer months used to have lot of prickly heat. Recently, happening more often, would go away when he works in AC room.

In 2021 Dec, went to Hyderabad for treatment of hemorrhoids. Also, c/o itchiness and papula with peeling of skin which resolved with ointment and medicine for allergy. Stayed in hospital for 11 days. Was prescribed medications. After returning home took 1 month complete rest. No more bleeding pr.

Then in Feb 2022, came to Hyderabad as an advocate for another patient. Returned home after staying in Hyderabad for 2-3 days. Pt suspect due to travelling for long hours in train, not bathing, eating spicy food, skipping proper meals resulted in recurrence in hemorraghic bleeding after he returned home. Stayed at home for 2-3 months, took complete rest and took all the medices prescribed. 

2-3 months later went to Kerala for work. After 1 month staying there, bleeding per rectum daily with burning sensation while passing stool. Came to Hyderabad, where colonoscopy and endoscopy was done. 

CURRENT CHIEF PROBLEMS  AND PATIENT'S REQ.: For the past 1-2 months blood comes out almost daily everytime he passes stool. Stool hard to pass and cannot clear bowel completely. Recurrence of gastric problems. No complain of abd. pain. But bloating, everytime after eating sour burps and flatulence with burning sensation in epigastrium. Vomited twice, once 10 days prior and once 3 days prior coming to Hyderabad. So much so that little blood also came out with vomit. 10 days ago, one episode of fever lasted for 3 days, for which had medicine as suggested by pharmacy, after fever did not decrease on taking paracetamol.

Started smoking at the age of 13-14 yrs. B/c had to do late night works. Initially 3-4 bidis/day, later 15-20 bidis/day. Fo the past 2-3 days, smoking 4-5 bidis/day. Started chewing tobacco at the age of 13-14 (2-3 times/day, 4 gms in total) Started alcohol 10 yrs ago due to peer pressure. Used to consume 100ml once or twice/wk. Stopped since last 2 months. Pt stopped eating non veg on own accord since past 2 months. 

FAMILY HISTORY: 

Father - Age 60 yrs. k/c/o DM since past 4-5 yrs, high cholesterol, HTN, SOB and heart ailments. Addiction - paan, nutmeg

Mother - k/c/o HTN, cholesterol and gastric issues(flatulence, bloating, burps). Osteoarthritis. Pain increases during winter season. Cannot walk for long

Elder brother - At young age had hemorrhoids Sx. Complete recovery. k/c/o Dm, obesity (wt 112kg)

REPORTS: 

PROVISIONAL DIAGNOSIS: Grade 3 hemorrhoids external with scabies with IBD, reflux esophagitis grade A, rectal ulcer - ?SRUS, int. hemorrhoids with rcs and external hemorrhoids