Ashok Kumar

Recovered

PT-10252MRD/2024/543551 yrs · Male+91 76354 70844Chennai

Blood Group

O-

BMI

20.6

Surgeon

Dr. Rajiv Kapoor

Surgery Date

11 Feb 2026

Patient Information

Full Name: Ashok Kumar
Age / Gender: 51 yrs · Male
Contact: +91 76354 70844
MRD Number: MRD/2024/5435
Blood Group: O-
City: Chennai
Admission Date: 10 Feb 2026
Anaesthesia: Saddle Block
BMI: 20.6

Clinical Findings

Chief Complaint

Severe pain during defecation with streak of blood

Symptoms

ConstipationSphincter spasmPainful defecationSentinel tag

Duration of Symptoms

5 months

Diagnosis

Chronic Posterior Anal Fissure

Past Medical History

HypothyroidismChronic constipationSmoker

Investigations

Test	Result	Status
Complete Blood Count	Hb 11.8 g/dL	Normal
MRI Pelvis / Fistulogram	No abnormal tract	Normal
Proctoscopy	Internal opening at 6 o'clock	Abnormal
Histopathology	Benign, no malignancy	Normal

Surgery Details

Procedure: Fissurectomy
Surgeon: Dr. Rajiv Kapoor
Anaesthesia: Saddle Block
Duration: 39 min
Blood Loss: 62 ml
Date: 11 Feb 2026

Operative Note

Lateral internal sphincterotomy performed; sentinel tag excised.

Post Operative Notes

Uneventful post-operative course. Ambulated same day. Pain controlled with oral analgesics.

Follow Up History

04 Mar 2026Pain score: 8/10
Recovery: SlowMedication: Metronidazole 400mg
Mild residual discomfort
17 Mar 2026Pain score: 6/10
Recovery: On trackMedication: Topical GTN 0.2%
Advised high-fiber diet
03 Apr 2026Pain score: 1/10
Recovery: SatisfactoryMedication: Topical GTN 0.2%
Suture line clean
31 Mar 2026Pain score: 2/10
Recovery: GoodMedication: Diclofenac SR
Mild residual discomfort

Diagnosis & Treatment

Primary Diagnosis

Chronic Posterior Anal Fissure

Anal Fissure

Planned Treatment

Fissurectomy

Next visit: Discharged

Complications

Post-op bleedingMinor

Managed conservatively with close monitoring. Documented for outcome tracking.

Attached Images

Pre-op Photo

MRI Scan

Histopath

Post-op Photo

Sample attachments · demo placeholders