External hemorrhoids are found (above/below) the pectinate line.
USMLE® Step 1 style questions USMLE
USMLE® Step 2 style questions USMLE
A 62-year-old man comes to the office because of painless rectal bleeding for the past 3 months. He describes the intermittent occurrence of streaks of “bright red blood” on the toilet paper after wiping, and blood on but not mixed within the stool. Occasionally he has noted a small volume of blood within the toilet bowl, and associates this with straining. For the past two weeks he has noticed an “uncomfortable lump” in his anus when defecating, which goes away by itself immediately afterwards. He says he has no abdominal pain, weight loss, or fevers. He is a well-appearing man with obesity. Digital rectal examination shows bright red blood on the examination glove following the procedure. Anoscopy shows enlarged blood vessels above the pectinate line. Which of the following is the most appropriate next-step in management?