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A 80-year-old female presented with the chief complaints of discharge from the perianal region since 15 days
History of Presenting Illness:
1/7/23: The patient was apparently asymptomatic before 1/7/23 when she developed a swelling that was a size of a coin in her perianal region which was initially not associated with any pain or fever. Her daughter reports seeing the swelling on the first day of the patient's complaint and said it did not appear inflamed and it was not assosciated with discharge.
4/7/23: The patient reported sudden and severe pain in her pelvic and perianal region that woke her up in the morning. The pain was of a dull aching type, intermittent, non radiating and with no aggravating factors. She reports no history of trauma to the region. She also had a fever and complained of her legs aching till her knees that day. She was given an unknown medication on this day that relieved her pain and fever temporarily. The patient continued using this medication intermittently in the following days to relieve her symptoms. The patient only ate one small meal on this day as she had loss of appetite.
5/7/23: The patient noted some discharge from the perianal region which was initially scant and non bloody.
6/7/23: Her symptoms persisted, with an increase in the intensity of pain in perianal region. Her daughter noticed soiling of her clothes and the foul smelling discharge. The patient started complaining of burning micturition
12/7/23: Patient started complaining of throat pain and difficulty swallowing (solids >liquids)
Hospital course:
16/7/23: She was brought to the casualty ward by her family. She was in severe pain and was shouting. The 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 psychosis and paranoia. 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.
...
History of past illness:
Strabismus of right eye since birth.
She was diagnosed with hypertension 10 years ago which she manages with Atenolol 50mg, twice a day. It was an incidental diagnosis made when she visited a local RMP for a fever.
History of minor head injury without any loss of consciousness, nausea, vomiting, blurring of vision 5 years ago; it was treated with 3 stitches for a laceration.
She was diagnosed with Chronic Kidney disease in February, 2023 that is being managed conservatively.
She has a history of psychosis that first occurred in February, 2023 that was managed with risperidone and clozapine 25mg for 2 months.
Medication History:
Uses an unknown syrup for her intermittent cough.
Surgical history:
Cataract surgery of the right eye 12 years ago and left eye 8 years ago.
Personal history:
She has decreased appetite and dysphagia, eats 1 small meal a day.
Bowel movements: 1/day, normal in consistency. Patient reports pain with stooling on the first two days after the onset of her symptoms.
Urine output: 2-3/day, burning on micturition.
Quit drinking toddy and chewing tobacco 20 years ago. No other drug use.
Food and drug allergies: No known allergies.
Daily routine:
She lives by herself. Before the onset of her illness she used to wake up at 4am. She spent her time until 9am cooking, cleaning and doing her laundry. 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.
Family History
No similar complaints in her family.
Her daughter was diagnosed with hypertension 5 months back.
General physical Exam:
On admission:
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
Systemic exam
Cardiovascular System: S1, S2 heard, no murmurs.
Respiratory System: BAE+, VBS, crepts+
Per Abdomen: Soft and nontender, no organomegaly.
CNS: C/C/C, AOx3, no focal neurological defects, CN function intact.
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:
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
- 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
What are the implications of late onset schizophrenia in this patient?
What could be the reason for her transient coagulopathy?
Is the CKD due to hypertension which is due to her visceral fat and is her current perineal abscess due to tuberculosis along with pulmonary due to her recent diabetes immunosuppression?
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