Subjective: 61 y/o female presents to proctology clinic today, referred from dermatology for pruritus ani. Pt reports she’s had pruritus for 1 year, used hemorrhoid cream without any relief. She followed up with dermatology who gave her hydrocortisone cream and then referred her here for evaluation. Pt states she had been using the hydrocortisone cream and Vaseline which has provided her with some relief. Pt admits to scratching and rubbing the area when itchy. Pt also notes she had a recent colonoscopy on 9/6/23 which showed small tubular adenoma sessile serrated polyp in cecum. Prep was sub-optimal and advised to repeat in 5 years. Pt denies fever, chills, constipation, change in bowel habits, rectal pain, rectal bleeding, and rectal drainage.
Objective:
Physical Exam:
Vitals: BP: 154/78. HR: 62 RR: 16 Temp:36.3 SpO2: Ht: Wt: 80.3 BMI: 33.44
General: appears clean and casually groomed, A&Ox3, not in acute distress
Anus: small skin tag noted posteriorly, no external hemorrhoid, fistula or fissure noted, on anoscope posterior midline small internal hemorrhoid noted, but no signs of strangulation or incarceration noted. No masses.
Assessment: 61 y/o female with pruritis ani, not due to hemorrhoids. Symptoms likely due to irritation and persistent scratching and rubbing.
Plan:
- Advised pt to keep area dry and clean, to avoid perspiration in that area
- Advised to buy OTC hydrocortisone cream for itchiness as needed
- Educated pt on anal pruritus, informational sheet given, strongly advised to avoid scratching or rubbing area to allow healing
- Continue to follow up with primary care
- Return to clinic as needed
