Patient Profile:
A 30-year-old female patient visited Ano-Cureveda Clinic under the care of Dr. Preeti Paliwal with severe complaints of extreme pain in the anal region and a sensation of a small mass.
History:
- The patient had been suffering from on-and-off constipation for the past two years.
- Stools were initially very hard, followed by softer consistency.
- Due to the pain and discomfort, her appetite was reduced.
- Past medical history revealed no hypertension, diabetes, COPD, thyroid disorder, or prior surgeries.
- She had a full-term normal delivery five years ago.
Examination Findings:
- A small sentinel tag was present at the 6 o’clock position.
- Active drop-wise bleeding from the anal region was observed.
- Digital Rectal Examination (DRE) was not performed due to severe pain.
Diagnosis:
Findings were suggestive of a chronic anal fissure with sentinel tag.
Treatment by Dr. Preeti Paliwal:
- Prescribed oral Ayurvedic medicines to regulate bowel movement and relieve constipation.
- Advised medicated ointment for local application to reduce pain, bleeding, and inflammation.
- Counselled the patient on dietary modifications including high-fibre food intake, adequate hydration, and lifestyle adjustments to prevent recurrence.
Outcome:
Within a short span of treatment, the patient reported significant relief.
- Pain and bleeding subsided.
- Appetite improved.
- She was able to resume her daily duties regularly without discomfort.
Conclusion:
This case highlights how Dr. Preeti Paliwal’s holistic approach, combining Ayurvedic medicines, local applications, and dietary counselling, provided effective relief from chronic anal fissure and restored the patient’s quality of life.