2. Particulars of the patient :
• Name - Siyam
• Age - 8 Years
• Gender - Male
• Religion - Islam
• Address - Fulpur , mymensingh
• Date of Admission - 7th november 2022
• Date of examination - 7th november 2022
3. Presenting complaints :
• History of Continuous Dribbling of urine Since
birth
• Constant soiling and passing of stool for 6 years
• History of all staged complete ARM on 18th Nov
2020
4. History of present illness :
According to statement of his informant mother Patient was
born with absence of anal opening . He also complaints
continuous dribbling of urine mixed with meconium after
birth .with these complaints admitted hospital at age of 2
days ( 4th Dec 2014 ) . Then pelvic colostomy was done 6th
Dec 2014 due to high variety ARM with rectourinary fistula
. After 2 years on 6th Nov 2016 abdominal assisted
anorectoplasty was done . Since then he developed constant
soiling and passing of stool . Then he complaints difficulty of
micturition as well as dribbling and subsequently diagnosed
as a case of meatal stenosis and on 18th Nov 2020 colostomy
reversion and meatotomy was done .
5. After that patient admitted to hospital for constant fecal
soiling and continuous urinary dribbling and on
examination anal stenosis was found . Then on 14th
August 2022 inverted V-Y anoplasty with
cystoscopic evaluation was done and found normal
urethral caliber with bladder trabeculation but no
urethral valve . Since then the patient was still suffering
from constant fecal soiling and urinary dribbling .Now
the patient is admitted to MMCH at Pediatric surgery
Dept. for better management .
6. Birth history
• Siyam was born with normal vaginal delivery at
term at home with an average weight with absence
of anal opening .
9. General
examination
• Appearance : normal
• Body built : average
• Anemia : mild
• Jaundice : not icteric
• Cyanosis : absent
• Clubbing : absent
• Dehydration : absent
• Edema : absent
• Pulse : 88 beat / minutes
• Temperature : normal
• R/R : 16 Breath / minutes
• Neck vein not engorged
• Lymph node : all accessible lymph node not palpable
10. Perineal examination : with privacy and
screening
• Inspection : Soiling with fecal material around the
anus and surrounding skin. skin excoriation
present and buttock was flat and a low, short gluteal
Cleft .
• Digital rectal examination : Anal tone and
anal grip was lost . Rectum was loaded with stool .
11. Per Abdominal Examination :
• Inspection : Abdomen is scaphoid shape . Umbilicus is
centrally placed and inverted . Flanks are not full . No
engorged vein or visible peristalsis . There is scar mark on
lower abdomen and LIF . Hernial orifices are intact .
• Palpation : Abdomen is soft and non tender . No muscle
guard or rigidity present . No organomegaly found.
• Percussion note : Tympanic
• Auscultation : Bowel sound is present .
12. CVS : 1st And 2nd Heart sound is audible
in auscultatory area . No added sound .
• Respiratory system :
• No significant abnormality
• Musculoskeletal examination :
• No other significant abnormality .
13. • Nervous system examination :
• Muscle tone , bulk are normal . Fine touch and
crude touch are intact on all dermatomes area
except around the anus . All jerk and reflex are
intact except Anal reflex .
14. Salient features :
• Siyam 8 years old boy hailing from fulpur ,mymensingh, presented to me
with the complaints of absence of anal opening and dribbling of urine
mixed with meconium at birth . At the age of 4 days pelvic colostomy
was done due to high variety ARM with rectourinary fistula on 6th Dec
2014 . On 6th Nov 2016 abdominal assisted anorectoplasty was done .
Since then he developed fecal incontinence . He also complaints difficulty
in micturition as well as dribbling and subsequently diagnosed as a case
of meatal stenosis and on 18th Nov 2020 colostomy reversion with
meatotomy was done . Then the patient came with fecourinary
incontinence and on examination was found anal stenosis. On 14th
august 2022 inverted V-Y Anoplasty with cystoscopic evaluation was done
and found bladder trabeculation with normal urethral caliber and
without any valve .
15. • His general survey is essentially normal except mild Anemia .
Abdomen is scaphoid , umbilicus is centrally placed , there is
scar mark on lower abdomen and LIF . No organomegaly
present . On rectal examination ,Perianal region was soiled
with stool, anal tone and grip is lost , anal reflex is absent and
loss of perianal sensetion . Other system reveals normal.
16. Provisional diagnosis :
• All staged complete Anorectal malformation with faecourinary
incontinence .
