65 yr old male with relapse of fistula in ano

 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 HISTORY: Pt is a 65 yr old male, working as an academician. 

At the age of 2 yrs, fractured his hand(right or left cannot remember) which was healed by a village Dr. Had no complaints about it afterward.

At the age of 12, had a history of chicken pox.

Pt reported that he believes since he belonged to a humble family background he did not receive adequate nutritive foods, so his immunity and digestive system is not strong. Hence, during his childhood days used to suffer from frequent episodes of fever lasting for 5-6 days sometimes with cough and cold.

In his early childhood days, c/o GI problems (3-4times/ yr incidents of food poisoning, nausea, vomiting, acidity, acute epigastric pain). Pt suspects that since they had no water purifier and used to drink water directly supplied by the corporation, which could have caused his digestion problems. Using homeopathy medicine would resolve these symptoms.

For the past 10-12 yrs, c/o sometimes mucus-laden stool of semi-solid consistency (2-3 times/day).

At present, after changing his lifestyle by eating light nutritive foods he feels his digestive problems have improved with no more epigastric pain, but reported a few incidents of vomiting 2-3 times/day and feeling less appetite all the time afterward for a few days.

A few years ago he c/o abd. cramps, diarrhea on drinking milk. Self-diagnosed himself as lactose intolerant and avoids milk and milk products.

7 yrs ago started c/o SOB and chest tightness while sleeping in the supine position. Symptoms would be noted while sleeping at night only which would appear just after lying down. Felt better while lying on either side. After reducing food intake and eating light foods the symptoms reduced.

In 2009, noticed swelling and tenderness near the anal region. Thought it to be a boil. It burst open and first blood then yellow pus discharge was noted. Dr. diagnosed it to be a fistula and prescribed medication which failed to improve the condition. He started ayurvedic treatment (oral medication and ointment), following which his symptoms started improving. He had to use cotton wipes to prevent spoilage of his undergarments. 

Thinking he has recovered completely he stopped taking the Ayurvedic medicines in 2014. 

After recently leaving his town of residence why? to live in another place for a few months, 2 wks ago he again noticed swelling and tenderness in the perianal region. Dr. referred him to a Surgeon who performed a rectal examination after which his swelling and pain increased. He was prescribed Norflox-TZ (Norfloxacin and Tinidazole) and Signoflam (aceclofenac, paracetamol, and serratiopeptidase) for a week. 2-3 days later, he noticed a yellow discharge stained with blood after which pain reduced. 

 He plans to start Ayurvedic treatment again if allopathy does not work.

For more than a year, he is c/o pain in the rt elbow joint.

20 days ago, he had eaten packaged frozen meat after which he vomited and his appetite decreased. when and how recovered?

He lives alone since 2005, because of marital disputes with his wife and since his only daughter lives in a foreign country. In 2020, his sister died because of covid which saddened him a lot. He feels seeking help from others will make him a burden to others so does not share his problems with anyone and tries to solve his own problems. 

Not a k/c/o HTN, DM.

At the age of 17, started smoking 1 cigarette/day. Stopped smoking after marriage, 35 yrs ago.

At age 22 went to a foreign land to study. Started drinking alcohol 1300 ml, 1-2times/month with friends). For the past 20 yrs drinking 20ml/day.

CURRENT CHIEF PROBLEMS  AND PATIENT'S REQ.: Pt wants a cure for his fistula in ano. 

FAMILY HISTORY: 

Father - DM. Smoked cigarette 2-3/day

Mother - often c/o bloatedness, indigestion