online solution: Mr. Average is a 40-year-old attorney who presents complaini

Mr. Average is a 40-year-old attorney who presents complaining of3-4 weeks of rectal itching.  He says that he has never had anything like this before, although he knows that he has some small hemorrhoids. He states that the itching seems to be worse at night.  He has used some A and D ointment on the rectal skin without much benefit.  He also tells you that he does suffer with constipation that began while he was in law school.  It seems to be worse right before he must go to court. With closer questioning, you discover that his diet is low in fiber, and that his main beverage is coffee.  He does not have any kind of routine exercise program.  He does tell you that he does have “occasional” painless BRB on the toilet paper, but only if he is constipated. Mr. Average is married; he does not smoke or use illicit drugs.  He and his wife have 3 children, all under the age of 8. On PE, he is a well-developed male, in NAD.  His vital signs are stable.  His BMI is 31. His cardiac and lung exam are normal. His abdominal exam reveals normal bowels sounds, without organomegaly.  The rectal exam reveals mucosa that appears a bit macerated.  The skin of the anal opening is a bit friable.  With Valsalva, you see 3 small bluish “lumps” that become visible.  Internal and external sphincter tones are normal; stool is negative for blood.   Health Science Science NursingNURSING MS NURS 5462