80 year old female with perianal abscess
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A 80 year old female, currently not working (used to be farmer by occupation),resident of Haliya was referred to medicine department from general surgery with complaints of low haemoglobin level.
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 2 months ago then she developed a swelling in perianal region that was in size of a coin which was insidious in onset and gradually progressive associated with fever.
The swelling was ruptured 15 days back and is associated with discharge.It is associated with dull aching pain.She was taken to the local RPM where the discharge was cleaned and dressing was done.IV antibiotics were administered.
5 days ago , patient was brought to casualty with similar complaints and was admitted in surgery department for further evaluation.
3 days ago, patient was shifted to medicine department due to low haemoglobin level (6.6 g/dl). Patient was given 1 unit of blood on 18/07/2023 and 4 units of blood on 19/07/2023.
Hospital course:
16/7/23: She was brought to the casualty ward and abscess was drained by General surgery and a dressing with hydrogen peroxide, betadine and NS was placed. The patient was also given neomol for the pain.
17/7/23: A psychiatry referral was done to investigate her history of auditory hallucinations . She was prescribed Olanzapine 25mg once a day and lorazepam as needed for irritability and disturbed sleep.
A pulmonology referral was also done in view of her productive cough that worsened in the past 15 days. She was prescribed ascoril syrup and an appetite stimulant. Sputum tests for AFB and CBNAAT were advised.
PAST HISTORY
Patient is a known case of hypertension since 10 years for which she was started on anti hypertensives (currently on TAB Atenolol 50mg).
She for was diagnosed with Chronic kidney disease 6 months ago and was started on conservative management which were used for 2 months and gradually stopped due to complaint of experiencing side effects
She sought for psychiatric consultation 6 months ago for complaint of auditory hallucinations.
Not a k/n/o diabetes/TB/CVD/Epilepsy/Thyroid disorders
FAMILY HISTORY : Her younger daughter is known case of hypertension since 1 year.
TREATMENT HISTORY :
She is on anti hypertensives since 10 years
She is also on oral laxatives since 10 years.
SURGICAL HISTORY
30 years ago, she had complaints of diminision of vision in both eye with left >>right, was diagnosed with cataract in left eye and underwent cataract surgery in left eye.
14 years ago, for similar complaints in right eye, underwent cataract surgery in right eye. 10 to 15th post operative day, she started having double vision that slowly resolved.
PERSONAL HISTORY
Diet: Mixed
Appetite: decreased
Sleep: inadequate
Bowel and bladder movements: decreased urine output since one year ; irregular Bowel movements
Additions: She used to consume 1 sutta per day which was stopped 15 years back.
No history of recent Addictions
Daily routine:
She lives by herself. Before the onset of her illness she used to wake up at 4am. Till 9 am doing house hold chores At 9am she usually ate one small meal. Her next meal was at 2pm after which she used to take a 1-2 hour nap. Her next two meals were at 5pm and 7pm. She has always had small meals that her family attributes to her getting older. She occasionally had a glass of milk before going to bed at 9 or 10pm.
She went to live with her daughter 2 weeks before the onset of her symptoms. Ever since the onset of her illness, she has had a loss of appetite, has been unable to work or walk around the house due to the pain and sleeps during the day. She reports having disturbed sleep due to the pain
GENERAL EXAMINATION
Patient is conscious,coherent, cooperative
Moderately nourished and built .
No pallor,Icterus, cyanosis, clubbing lymphadenopathy, edema.
VITALS
Afebrile (98.6)
BP: 130/70mmHg
HR: 114bpm
RR: 18cpm
SpO2: 98% on RA
GRBS: 150mg/dL
- Patient is conscious, coherent and cooperative, well oriented to time, place and person.
- No signs of pallor, cyanosis, icterus, lymphadenopathy, clubbing or pedal edema.
- JVP normal
Local examination:
Inspection: 2x2cm ulcer over the left perianal region, with sloping edges and purulent discharge. The discharge is foul smelling and slightly blood stained.
Palpation: Inspectory findings were confirmed. There is a local rise of temperature and tenderness over the ulcer. The ulcer measures 2x2x4cm and has pale granulomatous tissue. Pulses are normal and there is no regional lymphadenopathy.
Investigations
16/7/23:
CHEST XRAY: Impression: Increased bronchovascular markings with B/L hilar enlargement.
17/7/23:
ECG:
2D Echo: Impression:
Trivial TR, No MR/AR
No RWMA. No AS/MS. Sclerotic AV
Good LV systolic function
Diastolic dysfunction. No PE/PAH
ULTRASOUND, CHEST: Impression
Air sonograms in left lower zone of lung with minimal pleural effusion.
ULTRASOUND, ABDOMEN AND PELVIS: Impression
Right Grade II RPD changes
Left Grade III RPD changes
Right renal cortical cysts
Left renal calculus
19/7/23:
Provisional diagnosis: Ruptured perianal abscess in a case of CKD with anemia.
Treatment
FRESH FROZEN PLASMA:
19/7/23, 1AM: 1 UNIT
19/7/23, 2PM : 4 UNITS (started bag 1 at 2:05pm, ended bag 4 at 4:12pm)
IV FLUIDS NS UO+30ML/HR
TAB LORAZEPAM 1MG PO SOS
SYP ASCORYL 5ML ORAL TID
SYP APTIVATE (appetite stimulant)
INJ TETANUS TOXOID 0.5CC IM GIVEN ONCE
TAB BISACODYL PO/BD
INJ XYLOCAINE ID GIVEN ONCE AROUND THE SWELLING
INJ ERYTHROPOIETIN 4000IU SC 1/WEEK
TAB OROFER PO OD
INJ VITAMIN K
INJ LINEZOLID 600ML IV BD
INJ TRAMADOL 200ML IV BD
INJ NEOMOL 1GM IV SOS
TAB PANTOPRAZOLE 40MG PO OD
TAB ZOFER 4MG ORAL SOS
TAB NODOSIS 500MG PO OD
TAB SHELCAL PO OD
TAB OLANZAPINE 2.5MG PO OD
TAB PARACETAMOL 650MG PO BD
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