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A 60-year-old gentleman presents to you with a 3-day history of constant perianal pain and bright red blood seen in the toilet bowl. This morning, he noticed a small swollen mass at his anus when washing in the shower. He experienced a similar episode of pain and bleeding several months ago, which he attributed to hemorrhoids, but his symptoms today are far more severe.

  • What else in this patient's history might help to establish the diagnosis?
  • What characteristics of the pain and bleeding are important to know?
  • If the patient is correct about having hemorrhoids, are they likely internal or external?
  • Does this history cause concern for anal cancer?
  • Can you make the diagnosis based on this history alone?

Symptoms of anorectal disease are common. However, due to the reluctance of both patients and clinicians to discuss these symptoms in detail, problems may be attributed hastily to internal hemorrhoids and not investigated adequately. In many cases, a thorough history will point to a specific diagnosis, or at least help target the physical examination and indicate the appropriate special tests. No matter how clear the history seems to be, a perianal inspection and digital anorectal examination are mandatory unless the anal canal is too tender or too stenotic to allow this examination. Anoscopy is an important adjunct to the physical examination in patients with anorectal symptoms. After a detailed history, physical examination, and anoscopy, further or more invasive diagnostic testing may be unnecessary.

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