HISTORY:
Anal pain for
Onset:
Severity: , / 10
Type:
Pattern:
Worsening factors:
Treatments tried: ,
, , , clots
, episodes ,
, , ,
, up to °, over
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Abdomen: , , ,
Anorectal: DRE , prostate , anus
ASSESSMENT:
DDx:
PLAN:
- Blood work: ,
- Stool culture
- Rectal swab for chlamydia and gonorrhea
- Colonoscopy
- CT scan of abdomen and pelvis
-
-
-
- Incision and drainage of abscess
- Sitz baths
- Increase fluid intake
- Increase dietary fiber
- Referral to gastroenterologist
- Referral to general surgeon
- Follow-up in
- Return if symptoms worsen, if new symptoms develop such as weight loss or blood in stools, or if symptoms do not improve with treatment