Back to Registry
MP

Mohan Pillai

Recovered
PT-10257MRD/2024/228948 yrs · Male+91 91711 68282Kozhikode
Blood Group
A-
BMI
20.1
Surgeon
Dr. Vivek Bhaskar
Surgery Date
08 Dec 2025

Patient Information

Full Name
Mohan Pillai
Age / Gender
48 yrs · Male
Contact
+91 91711 68282
MRD Number
MRD/2024/2289
Blood Group
A-
City
Kozhikode
Admission Date
08 Dec 2025
Anaesthesia
Spinal
BMI
20.1

Clinical Findings

Chief Complaint
Severe pain during defecation with streak of blood

Symptoms

ConstipationSphincter spasm
Duration of Symptoms
5 weeks
Diagnosis
Chronic Posterior Anal Fissure

Past Medical History

Ischemic heart diseaseNo significant historySmoker

Investigations

TestResultStatus
Complete Blood CountHb 14.1 g/dLNormal
MRI Pelvis / FistulogramNo abnormal tractNormal
ProctoscopySinus opening seenAbnormal
HistopathologyChronic inflammationNormal

Surgery Details

Procedure
Botox Injection
Surgeon
Dr. Vivek Bhaskar
Anaesthesia
Spinal
Duration
48 min
Blood Loss
38 ml
Date
08 Dec 2025

Operative Note

Lateral internal sphincterotomy performed; sentinel tag excised.

Post Operative Notes

Patient tolerated procedure well. Vitals stable. Shifted to ward in satisfactory condition.

Follow Up History

  1. 17 Dec 2025Pain score: 6/10
    Recovery: ExcellentMedication: Metronidazole 400mg

    Advised high-fiber diet

  2. 01 Jan 2026Pain score: 3/10
    Recovery: SlowMedication: Diclofenac SR

    Mild residual discomfort

  3. 04 Jan 2026Pain score: 2/10
    Recovery: SatisfactoryMedication: Topical GTN 0.2%

    Fully healed, discharged from care

  4. 21 Jan 2026Pain score: 1/10
    Recovery: SlowMedication: Diosmin + Hesperidin

    Continue sitz baths

Diagnosis & Treatment

Primary Diagnosis

Chronic Posterior Anal Fissure

Anal Fissure
Planned Treatment
Botox Injection
Next visit: Discharged

Complications

No complications recorded — uneventful recovery.

Attached Images

Pre-op Photo
MRI Scan
Histopath
Post-op Photo

Sample attachments · demo placeholders