Clinical case presentation

Presented by-
Dr.Md.Jubaer Uddin
On behalf of
Department of Surgery,DCIMCH
Particulars of the patient
Nama: Mr.Almas Shikdar
Age: 19 yrs
Religion: Islam
Occupation: Student
Address: Road-7,Shakertek,Dhaka
Data of admission: 23/10/22
Date of examination: 23/10/22
Chief complaint
• Pain and discharge from gluteal furrow
for 2 years.
History of presenting illness:
According to the patient’s statement, he was
resonably well 2 years back. Then he developed
Painful intermittent discharge from gluteal furrow
which was purulent and foul smelling and didn’t not
improved with medication. Patient is otherwise
healthy, he is normotensive and nondiabetic.
Now he got admitted to this hospital for definitive
management.
History of past illness
History of appendisectomy 4 years back.

Drug history
He used to take Fluclox and Napadol for this illness.

Personal history
Nothing significant.

Occupational history
He is a student
Socio-economic history
He belongs to a middle class family.

Family history
All the members of his family are apparently
healthy.

Immunization history
He has received covid-19 vaccine.
Local Examinations
Inspection:
• Site: There is a sinus in the
gluteal furrow.
• Number: Single visible opening
and multiple pits.
• Discharge: Purulent and foul
smelling.
• Surrounding skin condition:
Normal
Palpation:
• Temperature: Not raised.
• Tenderness: Tender.
• Lump: Indurated area under the sinus opening in
the gluteal furrow.
DRE and proctoscopy revealed no abnormities.
Examination of draining lymph nodes: Not palpable
General Examinations
Appearance: Normal
Blood Pressure: 130/80 mmHg
Decubitus: On choice Pulse: 86 beats/min and regular
Cooperation: Cooperative Temperature: 98.6 *F
Respiratory rate: 18breaths/min
Body built: Average
Anemia,Jaundice,Cyanosis,Clubbing,
Koilonychia,Leukonychia,Dehydration: Absent
Lymph node: Not palpable
Salient features
Mr.Almas Shikder 19 years old,
normotensive nondiabetic, hailing from
Shakertek, Dhaka, admitted in this hospital
with the complaints of Painful intermittent
discharge from gluteal furrow which is
purulent and foul smelling and didn’t
improved with medication. Patient was
otherwise healthy.
On local examination there is a sinus in the gluteal
furrow, single visible opening and multiple pits are
present, there is purulent and foul smelling
discharge and surrounding skin condition is
normal.
Temperature is not raised but tender and there is
an indurated area under the sinus opening in the
gluteal furrow.
DRE and proctoscopy revealed no abnormities.
What may be
the provisional
diagnosis?
Provisional diagnosis
Pilonidal sinus
What may be the differential
diagnosis?
Differential diagnosis
• Sebaceous cyst
• Perianal fistula
• Perianal abscess
Pre-Anasthetic Check Up
• CBC
• S.Creatinin
• RBS
• Plain X-ray chest
• HBsAg
• Anti-HCV
Treatment
• Conservative treatment:
Medicaltion: Antibiotic.
Advice: Clean and shave the affected
region.
• Surgical Management:
Removal of the pilonidal sinus tract by-
– excision and laying open
– excision and primary closure
– excision and advancement flaps (e.g. Karydakis
procedure or a V–Y flap)
– excision and rotational flaps (e.g. Limberg flap)
Excision
followed by
Rhomboid flap
reconstruction
Operation note:
Indication: Pilonidal sinus with recurrent abscess.
Name of Operation: Rhomboid flap
reconstruction
Date of operation: 23.10.22
Time of operation: 1:00 pm
Anaesthesia: Spinal anaesthesia
Operation Procedure and findings:
Procedure: With all aseptic precaution after proper
painting and draping, mid line pit and pilonidal sinus cavity
was identify using methylene blue dye mixed with H2O2.
Entire sinus wall was excised. Rhomboid flap
reconstruction was carried out. Romo vac drain tube was
kept in situ.
Surgeon: Dr.Tamjeed Alam.
Anesthesiologist: Dr.NK Alam.
Assistant: Dr.Hasan, Dr.Jubaer.
Post operative order:
NPO for 3 hours then liquid followed by normal diet.
Inf. Lactoride 1L IV stat @30 drops/min.
Inj. Ceftron 1gm IV stat & 12 hourly.
Inj. Napa 1gm I/V stat & 8 hourly.
Inj.Toradolin 1amp IV stat & sos.
Inj. Emistat 1amp IV stat & 12 hourly
Inj. Sargel 40mg 1vial IV stat.
Postoperative events:
His postoperative period was uneventful. After
operation, his condition was improving. He was
discharged on 2nd POD with medication and
advice.
Discharge order:
Medication
• Cap.Rofixim 400mg 1+0+1____10days
• Cap.Clindacin 300mg 1+1+1____7days
• Tab.Napa One 1gm 1+1+1+1____5days
• Cap.Sergel 20mg 1+0+1____15days
Advice
• Keep bandage dry
• Maintain hygiene
Follow up
After 7 days.