A 33-Year-Old Man Comes to the Office Due to Persistent

question 822

Multiple Choice

A 33-year-old man comes to the office due to persistent anal pain.  Two months ago, the patient experienced severe anal pain associated with bowel movements.  Evaluation revealed an anal fissure and external hemorrhoids for which he was treated with stool softeners and topical nitroglycerine.  His symptoms have persisted despite adherence with the medical therapy and high-fiber diet.  He reports no history of anal trauma or anal intercourse.
Vital signs are within normal limits.  Rectal examination is painful and reveals a posterior midline anal fissure, large skin tag, and external hemorrhoids with no thrombosis.  The remainder of the physical examination shows no abnormalities.
Blood cell counts and serum chemistry studies are within normal limits.  Which of the following is the most appropriate next step in management of this patient's disorder?

• A)Anal ulcer biopsy to rule out malignancy
• B)Colonoscopy to rule out Crohn disease
• C)Rapid plasma reagin test for syphilis
• D)Rubber band ligation of the hemorrhoids
• E)Serologic tests for celiac disease

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Definitions:

Mental Disorder

A health condition characterized by alterations in thinking, mood, or behavior associated with distress or impaired functioning.

Nervousness

A common emotional response to stress characterized by feelings of anxiety, unease, and apprehension.

Social Phobia

An anxiety disorder characterized by a significant amount of fear in one or more social situations, causing considerable distress and impaired ability to function in at least some parts of daily life.

Depression

A common and serious mood disorder that affects how a person feels, thinks, and handles daily activities, characterized by persistent feelings of sadness and/or a lack of interest in previously enjoyed activities.