Date:
Patient:
Reason for Visit:
Rectal foreign body removal
Assessment of rectal injury and potential complications
History:
Presenting Illness:
Time of foreign body insertion (if known)
Description of foreign body (material, size, shape)
Symptoms (e.g., rectal pain, bleeding, tenesmus, difficulty passing stool)
Attempts at self-removal (important to document)
Past history of rectal foreign body insertion (if applicable)
Past Medical History (PMH):
Underlying medical conditions (e.g., mental illness, dementia)
Prior surgeries (abdominal or pelvic)
History of rectal bleeding or hemorrhoids
Social History:
Mental health history (important for risk assessment)
Physical Exam:
General: Assess for signs of pain, distress, or dehydration.
Abdominal: Palpate for abdominal tenderness or masses.
Perianal: Evaluate for external signs of injury or inflammation.
Digital rectal exam (DRE): Performed with extreme caution to locate the foreign body, assess for rectal wall integrity, and determine mobility of the object.
Diagnostic Tests (may be ordered depending on clinical presentation):
X-ray (abdominal and pelvic): May be helpful to visualize radiopaque objects.
CT scan (pelvis and abdomen): Can provide a more detailed view of the foreign body, surrounding tissues, and potential complications (perforation).
Assessment:
Type and location of foreign body: Based on history, physical exam, and imaging studies.
Risk of complications: Perforation, bleeding, rectal injury.
Suitability for removal in the emergency department setting: Depends on object characteristics, ease of retrieval, and potential for complications during removal attempt.
Plan:
Foreign body removal:
Manual extraction under direct visualization with anoscopy or rectoscopy (if object is within reach and easily grasped).
Instrumental removal under fluoroscopy guidance (for larger or impacted objects).
Surgical intervention (may be necessary for complex cases or suspicion of perforation).
Management of rectal injury (if present): Antibiotics, bowel rest, and potential surgical repair.
Evaluation for underlying mental health conditions: Referral to a mental health professional for further assessment and management (if indicated).
Patient education: Provide information about the risks and benefits of removal procedures, potential complications, and importance of seeking medical attention promptly in case of future foreign body insertion.
Discuss the importance of mental health evaluation and available support resources (if applicable).
Follow-up:
Depending on the removal method and presence of complications:
Schedule for a follow-up visit to assess healing and address any ongoing concerns.
Instruct the patient to return promptly if they experience worsening pain, fever, rectal bleeding, or difficulty passing stool.
Disclaimer: This information is for educational purposes only and should not be interpreted as medical advice. Please consult with a qualified healthcare professional for diagnosis and treatment of rectal foreign body insertion.