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RN

Rahul Nair

Under Follow-up
PT-10274MRD/2026/211136 yrs · Male+91 71656 13708Trivandrum
Blood Group
O+
BMI
20.0
Surgeon
Dr. Vivek Bhaskar
Surgery Date
25 Jun 2026

Patient Information

Full Name
Rahul Nair
Age / Gender
36 yrs · Male
Contact
+91 71656 13708
MRD Number
MRD/2026/2111
Blood Group
O+
City
Trivandrum
Admission Date
23 Jun 2026
Anaesthesia
Spinal
BMI
20.0

Clinical Findings

Chief Complaint
Severe pain during defecation with streak of blood

Symptoms

Painful defecationSphincter spasm
Duration of Symptoms
1 weeks
Diagnosis
Chronic Posterior Anal Fissure

Past Medical History

Chronic constipationDiabetes Mellitus Type 2

Investigations

TestResultStatus
Complete Blood CountHb 14.1 g/dLNormal
MRI Pelvis / FistulogramNo abnormal tractNormal
ProctoscopyGrade III pilesAbnormal
HistopathologyBenign, no malignancyNormal

Surgery Details

Procedure
Fissurectomy
Surgeon
Dr. Vivek Bhaskar
Anaesthesia
Spinal
Duration
76 min
Blood Loss
51 ml
Date
25 Jun 2026

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. 05 Jul 2026Pain score: 7/10
    Recovery: SatisfactoryMedication: Diosmin + Hesperidin

    Advised high-fiber diet

  2. 13 Jul 2026Pain score: 4/10
    Recovery: On trackMedication: Diclofenac SR

    Advised high-fiber diet

Diagnosis & Treatment

Primary Diagnosis

Chronic Posterior Anal Fissure

Anal Fissure
Planned Treatment
Fissurectomy
Next visit: 26 Jul 2026

Complications

No complications recorded — uneventful recovery.

Attached Images

Pre-op Photo
MRI Scan
Histopath
Post-op Photo

Sample attachments · demo placeholders