25 yr old female with c/o blood in stool and painful defaecation


PATIENT HISTORY: Pt is a 25 yr old lady, student, works as a private tutor. At the age of 18, she had an episode of allergic rash on her face(4-5 itchy red bumps). Lasted for 1 month. The dermatologist gave her medicine and told her to avoid eggs, hilsa fish, and prawns for the time being. Complete recovery. No recurrence. For the last 4 months avoiding these foods on own accord.

When in college life she used to eat spicy street food very often, but each time used to have gastric problems (burping, abd. pain, bloating) because of it. Pain used to go away on taking Aciloc.

4 months ago, 2 days before a marriage occasion in her home she noticed blood coming out mixed with stool. The stool was of normal consistency, but light yellow with mucus and blood and excruciating pain while passing stool. Dr. prescribed medicine that did not work. The patient used to pass stool 7-10 times. Blood used to come out 2-3 times mixed with stool and stool sometimes very hard to pass, while sometimes of normal consistency and normal brown color. She tried homeopathy which also failed. Again visited Dr. who told her that maybe it's an infection, told her not to eat spicy food, and gave medicines accordingly. But after taking the medicine her stool became very hard and painful to pass and frequent blood used to come out. So, stopped medicine on her own after 2 days. A second Dr. recommended her USG(an incidental finding of stone measuring 3.5 mm in rt. kidney; patient in no pain/discomfort because of it), colonoscopy(  ulcerated lesion detected 5cm from anal verge), biopsy (low grade dysplasia). Dr. prescribed Zanocin oz (taking for the past 1.5 months), Rifagut (taking for past 20 days; to reduce stool freq.).

CURRENT CHIEF PROBLEMS  AND PATIENT'S REQ.: For the past 4 months although not eating any spicy food(except during the days of the marriage), she is having frequent gastric problems(burping, acidity). For the past 2 months, pt is passing stool 5-6 times daily, small amount each time, feels as if the bowel not emptying completely. No blood. Burning sensation only if she passes stool for more than 4-5 times. Feeling of incomplete bowel clearance. Sometimes pus is coming out with stool. She also experiences left. side abd. pain with other gastric issues, and the pain goes away within a few hours if she takes Aciloc. She had to compress her and. with a pillow to try to reduce pain.


DIET: For the past 2 yrs she is dieting to keep herself fit. 

Diet plan:

After waking up - lemon water in empty stomach. Then tea before going for tuition

Goes to do tuition where she drinks 2 cups of tea. 

10:30 return home. Eats puffed rice/roti/bread/curd/milk

1:30 - lunch (rice, fish, sabji)

Evening - tea (in tuition)

Dinner - prefers roti with sabji/daal/fish

Used to eat lot of chicken 4 months ago. Completely stopped on seeing colposcopy results on own accord. Consumes dried amla to increase appetite.

FAMILY HISTORY: Mother has had external hemorrhoids for more than 25 yrs. Underwent 2 Sx, but not cured. No HTN, DM.

Father - used to consume alcohol 500 ml (2-3 times weekly with friends). Due to heavy losses in business (did different business like poultry farm, car renting) heavy drinker in the last 2 yrs of life (more than 2-3 bottles/ day). Sometimes only alcohol without any food the whole day. Was a smoker (10 - 15 cigarettes/day). Often complained of pain in abd. for last 2 yrs. Admitted in hospital with severe abd. pain and ascites. Died 10 yrs ago at age 42. 

Younger brother - no health issues

REPORTS:



                                         






FINAL DIAGNOSIS: Rectal Ca








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