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    Mrs. Vinita DS Details

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    Hemant Jangid
    Mrs. Vinita, age 40, presented with painful defecation and perianal swelling and was diagnosed with perianal abscess and fistula-in-ano. She underwent incision and drainage of the abscess with seton placement. Post-operatively, her condition was uneventful and she was discharged in a stable condition with medications including antibiotics and sitz bath instructions. She was advised to follow-up after 7 days and seek urgent care if fever, vomiting, severe pain or excessive bleeding/pus develops.

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    Mrs. Vinita DS Details

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    Hemant Jangid
    33 views3 pages
    Mrs. Vinita, age 40, presented with painful defecation and perianal swelling and was diagnosed with perianal abscess and fistula-in-ano. She underwent incision and drainage of the abscess with seton placement. Post-operatively, her condition was uneventful and she was discharged in a stable condition with medications including antibiotics and sitz bath instructions. She was advised to follow-up after 7 days and seek urgent care if fever, vomiting, severe pain or excessive bleeding/pus develops.

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    1705378757760_Mrs._Vinita_DS_Details

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    Mrs. Vinita, age 40, presented with painful defecation and perianal swelling and was diagnosed with perianal abscess and fistula-in-ano. She underwent incision and drainage of the abscess with seton placement. Post-operatively, her condition was uneventful and she was discharged in a stable condition with medications including antibiotics and sitz bath instructions. She was advised to follow-up after 7 days and seek urgent care if fever, vomiting, severe pain or excessive bleeding/pus develops.

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    33 views3 pages

    Mrs. Vinita DS Details

    Uploaded by

    Hemant Jangid
    Mrs. Vinita, age 40, presented with painful defecation and perianal swelling and was diagnosed with perianal abscess and fistula-in-ano. She underwent incision and drainage of the abscess with seton placement. Post-operatively, her condition was uneventful and she was discharged in a stable condition with medications including antibiotics and sitz bath instructions. She was advised to follow-up after 7 days and seek urgent care if fever, vomiting, severe pain or excessive bleeding/pus develops.

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    DISCHARGE SUMMARY

    PATIENT’S NAME: Mrs. Vinita UHID: 0

    AGE: 40 DATE OF ADMISSION: :15-01-2024

    GENDER: Female DATE OF OPERATION: 15-01-2024

    PATIENT’S ADDRESS: DATE OF DISCHARGE: 16-01-2024

    PATIENT’S CONTACT NUMBER: ROOM/BED NO:

    CONSULTANT: Dr. Tushar Mohan

    DIAGNOSIS:
    Perianal Abscess with Fistula in ano

    CHIEF COMPLAINTS:
    Painful defecation with swelling & redness around anus with pus discharge from perianal region since 3
    months.

    PAST HISTORY:
    Nothing Significant

    CLINICAL EXAMINATION ON ADMISSION:


    GC : Fair
    Vitals stable
    RS : NAD
    CNS : NAD

    PROCEDURE DONE:
    Incision & Drainage of Abscess with Seton placement done.

    Anesthesia:
    SA

    OPERATIVE FINDINGS:
    Large left perioneal abscess +
    EUA + proctoscopy - Internal opening at anal verge.
    Between 12 -1 'o clock position pus drained.
    Incision and drainage done ~ 50 ml
    Seton placement.
    Lavage done.
    Packing done.

    COURSE IN HOSPITAL:
    Patient was admitted with the above mentioned complaints. Patient was thoroughly evaluated and
    relevantly investigated. After informed/written consent and PAC clearance, the patient was taken to OT
    for the above mentioned procedure. Post procedure period was uneventful. Patient was managed with
    IV fluids, antibiotics, antiemetic, PPI, analgesics and other supportive measures. Patient was gradually
    improved and the patient is now being discharged in satisfactory condition with following advice.

    CONDITION AT DISCHARGE:
    Patient is afebrile, vitals are stable, accepting oral diet. Surgical wounds are healthy and no bleeding
    noted.

    MEDICATION ON DISCHARGE:

    DRUG DOSE ROUTE FREQUENCY DURATION

    TAB. ZIFI 200 MG PER ORALLY TWICE A DAY 5 DAYS

    TAB. METROGYL 400 MG PER ORALLY THRICE A DAY 5 DAYS

    TAB. RAZO 20 MG PER ORALLY ONCE A DAY 5 DAYS

    TAB. FLEXON 1 TAB PER ORALLY TWICE A DAY 5 DAYS

    SYP. CREMAFFIN 20 ML PER ORALLY AT BED TIME 5 DAYS


    ( NIGHT )

    SITZ BATH THRICE A DAY

    ANO METROGYL LOCAL APPLICATION


    OINTMENT

    TAB. STICOM FORT 1 TAB PER ORALLY ONCE A DAY 14 DAYS

    FOLLOW UP ADVICE:
    Fibre rich diet as advised
    Avoid oily and spicy food as advised
    Avoid lifting heavy objects x 1 month
    Avoid straining
    Avoid constipation
    Review in OPD after 7 days with prior appointment (+91-7303763211)
    To connect with Hospital POC contact on - 9044480800,

    WHEN TO OBTAIN URGENT CARE:


    If patient develops fever, recurrent vomiting, severe pain, excessive bleeding / pus discharge.

    ~Dr. Tushar Mohan


    MBBS
    MS - General Surgery

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