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Your next patient in a general practice setting is a 25
year old young man, Mr. Evans who has suffered
from rectal bleeding for the last 3 weeks.
 Take a history
 Perform an examination (You actually do not
examine the patient but you have to ask the
examiner how you go about it and what you are
looking for. The examiner will only mention the
findings if you ask for them!!!)
 Discuss your diagnosis and management with the
 Answer any questions

PHx: no previous illnesses or operations. MANAGEMENT / INVESTIGATIONS:  STOOL culture (because of recent o/s travel)  PROCTOSCOPY: reveals three internal first degree haemorrhoids at 3. recently married.HISTORY: For the last three weeks Mr. The blood is not mixed with the stool but is on the outside. regular faecal occult blood tests and colonoscopy starting at age 40. He has been reading up on Crohn’s and ulcerative colitis but feels that he does not have any classical symptoms for these conditions. especially on inspection of the anal area there are no fissures. He got some antibiotics from a local chemist and it settled after a few days. SHx: structural engineer. normal number of defecations per day. About 6 weeks ago he was on his honeymoon in Thailand and whilst there he had a bout of diarrhea. fistulas. EXAMINATION: Well looking young man.7 and 11 o’clock  Sigmoidoscopy / colonoscopy normal .g. no change in weight or loss of appetite. Evans has noted bright red blood when he had to open his bowels. e. very unlikely but the patient might ask  Colo-rectal cancer very unlikely but with his father’s ca the patient requires colonoscopy and follow-up investigations. tears. piles. He also found bright red blood on the toilet paper. normal BMI. no diarrhoea. non smoker. occasional alcohol. no mucous. no constipation. no pain. DIAGNOSIS: (Remember your task at this stage is not any further investigations but the diagnosis!)  HAEMORRHOIDS (most likely)  Consider infective colitis with the travel history (unlikely)  Inflammatory colitis etc. No other symptoms. no medication. No abnormal findings on physical examination. The pr examination is normal. warts or skin tags. no allergies FHx: father (49 years of age) has been recently diagnosed with bowel cancer although no further details available at present. otherwise unremarkable. Vital signs normal.

Pain is usually more likely to :  Fissure-in-ano  Perianal haematoma  Perianal or ischiorectal abscess  Tumour of the anal margin  Proctalgia fugax (benign episodic pain relieved by digital dilatation of the anal sphincter. Rx:      Avoid straining. they can be internal or external. they bleed (bright red blood at defaecation) but don’t prolapse Second degree: prolapse on defaecation but then reduce spontaneously. 7 and 11 o’clock. excessive use of purgatives. chronic constipation or rectal carcinoma Anorectal varices. They may produce mucous and pruritus Third degree: remain prolapsed outside the anal margin.g. First degree: confined to the anal canal. fluid intake. they may be manually replaced by the patient Etiology:   Idiopathic (usually precipitated or aggravated by congestion of the superior rectal veins. e. pregnancy. aim for soft stool (bulk laxative.HAEMORRHOIDS: Usually positoned at 3. usually in conjunction with portal hypertension H. are normally painless except when they thrombose. fibre diet) Treatment with local cream or suppositories Sclerotherapy Banding Haemorrhoidectomy (third degree ) .