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AS

Ashok Sharma

Under Follow-up
PT-10327MRD/2025/596050 yrs · Male+91 91599 44257Kozhikode
Blood Group
O+
BMI
20.0
Surgeon
Dr. Farida Sheikh
Surgery Date
16 Jun 2026

Patient Information

Full Name
Ashok Sharma
Age / Gender
50 yrs · Male
Contact
+91 91599 44257
MRD Number
MRD/2025/5960
Blood Group
O+
City
Kozhikode
Admission Date
14 Jun 2026
Anaesthesia
Local
BMI
20.0

Clinical Findings

Chief Complaint
Recurrent perianal discharge with external opening

Symptoms

Perianal painPerianal dischargeSkin excoriation
Duration of Symptoms
3 weeks
Diagnosis
Trans-sphincteric Anal Fistula

Past Medical History

No significant historyIschemic heart diseaseSmoker

Investigations

TestResultStatus
Complete Blood CountHb 14.1 g/dLNormal
MRI Pelvis / FistulogramTrans-sphincteric tract notedAbnormal
ProctoscopyChronic fissureAbnormal
HistopathologyBenign, no malignancyPending

Surgery Details

Procedure
Fistulotomy
Surgeon
Dr. Farida Sheikh
Anaesthesia
Local
Duration
48 min
Blood Loss
108 ml
Date
16 Jun 2026

Operative Note

Trans-sphincteric tract laid open (fistulotomy) with curettage.

Post Operative Notes

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

Follow Up History

  1. 29 Jun 2026Pain score: 8/10
    Recovery: On trackMedication: Diclofenac SR

    Continue sitz baths

Diagnosis & Treatment

Primary Diagnosis

Trans-sphincteric Anal Fistula

Anal Fistula
Planned Treatment
Fistulotomy
Next visit: 28 Jul 2026

Complications

No complications recorded — uneventful recovery.

Attached Images

Pre-op Photo
MRI Scan
Histopath
Post-op Photo

Sample attachments · demo placeholders