CLINICAL HISTORY

Date: July 19, 2008

General Data:
Mr. R.T. is a 25 years old, single male, Iglesia ni Christo, living in Canelar, Zamboanga
City. First time admitted at Zamboanga City Medical Center on July 14 2008

Referral: None
Source and Reliability: From the patient, 95% reliable.
 
Chief Complaint: Rectal Prolapse

History of Present Illness:

10 months prior to admission patient experienced hematochezia. Bowel movement is
every two to three days. Pain upon defecation is experienced. There is no abdominal pain, fever,
vomiting and abdominal distention. No medication or consult was done. Patient did “hot seat”
but afforded no relief.
Patient experienced rectal prolapse hence the addmission

Past History:
Patient doesn’t drink any vitamins or medications. Has no previous hospitalization

Family History:
The patient denies any heredo-familial disease such as cancer, allergies, hepatitis,
diabetes and hypertension

Personal and Social History:

The patient is a non-smoker and doesn’t drink alcoholic beverages. Patient’s usual diet
consists of rice, bread, vegetables, and meat.

Review of System
General: (-) fever, (-) chills, (+) weight loss of 5kg in 2 weeks
Skin: (-) itchiness, (-) lesions, (-) lumps, (-) pallor, (-) flushing, (-) discharge (-) dry skin
Head: (-) dizziness, (-) headache, (-) discharges, (-) rashes, (-) bleeding
Eyes: (-) redness, (-) blurred vision
Ears: (-) discharge, (-) bleeding, (-) hearing loss
Nose: (-) mucus discharge, (-) nosebleed
Mouth and Throat: (-) dry lips, (-) rashes, (-) difficulty in opening the mouth
Neck: (-) lumps, (-) tenderness
Chest: (-) cough
Cardiac: (-) chest pain
GIT: (-) nausea, (-) vomiting, (-) bleeding, (-) pain, (-) diarrhea
 Urinary: (-) incontinence, (-) pain on urination, (-) inability to urinate
Reproductive: (-) mucus discharge
Musculoskeletal: (+) weakness, (-) pain on the left arm, (-) joint pain
Neurologic: (-) altered sensorium

 Physical Examination:
           
General Appearance: The patient is conscious, coherent, ambulatory, not in respiratory
distress, and afebrile.

Vital signs:
Blood pressure: 110/80 mmHg
Respiratory rate: 20 breaths/minute
Pulse Rate: 50 beats/minute
Temperature: 36.6OC

HEENT:
Head – normo-cephalic and symmetric
Eyes –pink palpebral conjunctivae
Ears – no lesions, no discharges
Nose –no lesions, no discharges, no nasal flaring
Throat and Neck – trachea not deviated, JVP not prominent

Chest and Lungs

Inspection: Symmetrical chest expansion, no intercostal and supraclavicular
retractions.
Palpation: No chest lagging
Auscultation: No wheezes or rales.

Heart/CVS
Inspection: No precordial bulge
Auscultation: No murmur, regular rate and rhythm.

Abdomen
Inspection: No lesions and no rashes, abdomen not distended
Auscultation: normo-active bowel sounds
Palpation: No mass palpated, (-) direct and rebound tenderness

Extremities:
Normal capillary refill, no lesions
Working Diagnosis
Rectal prolapse secondary to hemorrhoids

Paraclinicals:
1. CBC
2. stool exam
3. abdominal X-ray
4. sigmoidoscopy

Case Discussion:

Hemorrhoids generally cause symptoms when they become enlarged, inflamed,

thrombosed, or prolapsed.
low-fiber diets cause small-caliber stools, which result in straining with defecation. This
increased pressure causes engorgement of the hemorrhoids. Aging causes weakening of the
support structures, which facilitates prolapse. Weakening of support structures can occur as early
as the third decade of life.
Portal hypertension has often been mentioned in conjunction with hemorrhoids.
Hemorrhoidal symptoms do not occur more frequently in patients with portal hypertension than
in those without.
Anorectal varices are common in patients with portal hypertension. Varices occur in the
mid rectum, at connections between the portal system and the middle and inferior rectal veins.
Varices occur more frequently in patients who are noncirrhotic, and they rarely bleed. Treatment
is usually directed at the underlying portal hypertension. Hemorrhoidal symptoms are divided
into internal and external sources. Internal hemorrhoids cannot cause cutaneous pain, as they are
above the dentate line and are not innervated by cutaneous nerves. They can bleed, prolapse and
cause perianal itching and irritation. Irritation and itching is caused by deposition of an irritant
onto the sensitive perianal skin.  Internal hemorrhoids can cause perianal pain by prolapsing and
causing spasm of the sphincter complex around the hemorrhoids. This spasm results in
discomfort while the prolapsed hemorrhoids are exposed. This muscle discomfort is relieved
with reduction. Internal hemorrhoids can also cause acute pain when incarcerated and
strangulated. Again, the pain is related to the sphincter complex spasm. Strangulation with
necrosis may cause more deep discomfort. When these catastrophic events occur, the sphincter
spasm often causes concomitant external thrombosis. External thrombosis causes acute
cutaneous pain. This consternation of symptoms is referred to as acute hemorrhoidal crisis. It
usually requires emergent treatment.
Internal hemorrhoids most commonly cause painless bleeding with bowel movements.
The covering epithelium is damaged by the hard bowel movement and the underlying veins
bleed. With spasm of the sphincter complex elevating pressure, the internal hemorrhoidal veins
can spurt.
 Management:

Treatment is divided by the cause of symptom into internal and external treatments.
Internal hemorrhoids do not have cutaneous innervation and, thus, can be destroyed without
anesthetic. Internal hemorrhoids are classified by symptom and are grouped into 4
stages. Conservative treatment includes increasing fiber and liquid intake and retraining in toilet
habit. Decreasing straining and constipation shrinks internal hemorrhoids and decreases their
symptoms. Numerous methods to destroy internal hemorrhoids are available; they include rubber
band ligation, sclerotherapy injection, infrared photocoagulation, laser ablation, carbon dioxide
freezing, Lord dilatation, stapled hemorrhoidectomy, and surgical resection. All of these methods
except stapled hemorrhoidectomy and surgical resection are considered nonoperative treatments
and should be the first-line treatment of all first- and second-degree internal hemorrhoids that do
not respond to conservative therapy. Operative resection is reserved for patients with third- and
fourth-degree hemorrhoids, patients who fail nonoperative therapy, and patients who also have
significant symptoms from external hemorrhoids or skin tags.

Acute lower GI
bleeding

No hemodynamic Hemodynamic
Instability instability

Upper
Age < 40 years Age > 40 years
endoscopy

Flexible
Colonoscopy Colonoscopy
sigmoidoscopy

Mild to moderate Severe bleeding

Bleeding stops
bleeding persists persists

enteroscopy, video
capsule Enteroscopy Angiography
enteroclysis

angiography Enteroscopy

Suggested algorithm
for lower GI Video capsule
Intraoperative
endoscopy
bleeding
Intraoperative
endoscopy

Beau S Piccio
Level 2