Chief Complaint: “Bloody Poop”x 1 day
History of Present Illness:
13 y/o BIB father after noticing painful bloody bowel movements since yesterday.
Patient states before the onset of bloody stool, he was going to the bathroom every 2 days for a week and stated stool was coming out hard and pebble-like. Patient states yesterday he experienced a painful bowel movement(7/10) associated with straining to pass stool when he noticed blood on the toilet paper after wiping.Patient describes the pain associated with bowel movements as a tearing pain. Patient states pain associated with bowel movement goes away after stool is passed. Last bowel movement was this morning around 9AM which the patient’s father states was also bloody. Patient denies any recent diet changes, and father states diet at home is usually takeout food. Patient father denies giving any medication to help alleviate pain. Patient denies any loss of appetite, nausea and vomiting, dysphagia, abdominal pain, diarrhea.
Medications:
None
Medical history:
Denies
Surgical History:
None
Immunization Hx:
Per CIR Database: All immunizations up to date
Allergies:
NKDA,No known food or environmental allergies
Family History:
Father: Alive 40 yrs, medical history of HTN
Mother: Alive 35 yrs, no known medical history
Social History:
T.A is a 13 y/o boy who is in shared custody between mother and father. TA lives with father during the weekdays in Jamaica, Queens.
Diet: Admits to a diet high in fatty foods
Sleep: 8-9 hours of sleep daily
Exercise: Exercises only when instructed in school. Does not play sports outside of school
Travel: Denies recent travel
Safety Measures: Father drops son to school daily.
Review of Systems:
General: Denies fever, chills, fatigue, loss of appetite.
Skin, hair, nails: Denies changes in texture, discolorations, rashes, or pruritus.
Head: Denies headache, head trauma, dizziness.
Eyes: Denies swelling, pruritus, warmth, and erythema.
Ears: Denies pruritus, pain, discharge, or hearing loss.
Nose/sinuses: Denies discharge, congestion, epistaxis and obstruction.
Mouth/throat: Denies bleeding gums, mouth ulcerations, sore throat, voice changes.
Neck: Denies swelling or decreased range of motion.
Pulmonary System: Denies shortness of breath, cough, wheezing.
Cardiovascular System: Denies chest pain or palpitations.
Gastrointestinal System: Constipation(hard pebble shaped stool), pain in anal region associated with hematochezia x 1 day. Denies nausea,vomiting, abdominal pain, diarrhea.
Genitourinary: Denies urinary frequency, urgency, dysuria.
Musculoskeletal System: Denies deformity, swelling, pain.
Hematological System: Denies easy bruising or bleeding.
Nervous System: Denies sensory disturbances, weakness,
Physical:
General: 13 y/o healthy male appears as his stated age, in no acute distress, dressed appropriate for the weather and A&O x3.
Vitals:
Temperature: 97.4 F
Height: 64 inch
Weight: 116lb
BMI: 19.91 /67.86%
Respiratory Rate: 19
BP:Not taken
PHYSICAL EXAM
Skin: No masses, scarring or bruising noted. Skin warm and nonicteric.
Hair: Average quantity. No lice or seborrhea noted.
Nails: No spooning or clubbing of nails.
Head: Head normocephalic, atraumatic.
Eyes: Symmetrical OU. Sclera white. Conjunctiva pink.
Ears: Symmetrical, no swelling or lesions to the external ear. No discharge or foreign bodies present AU. TM pearly grey with light reflex in good position AU.
Nose: Nares patent bilaterally. No discharge or foreign bodies noted.
Mouth/Pharynx: Lips pink and moist with no cyanosis or lesions. Buccal mucosa pink and well hydrated. Good dentition, no obvious dental caries noted. No gingival hyperplasia or erythema present. Uvula midline. Tonsils present with no exudates.
Neck/Thyroid:The trachea is midline without masses or scars. No anterior cervical lymphadenopathy on palpation.
Cardiac:Regular rate and rhythm, S1 and S2 present on auscultation. No murmurs, gallops, rubs, S3, or S4.
Lungs: Clear to auscultation bilaterally, no adventitious sounds noted.
Abdomen: Abdomen flat and symmetric, non-distended, no masses, ecchymosis or striae noted. Bowel sounds normoactive in all four quadrants. Non-tender to palpation, no guarding or rebound noted.
Musculoskeletal: No soft tissue swelling. FROM in upper and lower extremities.
Rectal: Fissure 6 o’clock. Tender on palpation, leaking from site.
Assessment:
13 y/o male, with no PMHx presents to outpatient pediatric clinic for painful hematochezia for 1 day. Physical exam showed a anal fissure in the 6 o’clock position from the rectal opening.
DDx:
Anal Fissure
Hemorrhoids
Gastrointestinal infection(Shigella)
Plan:
#Anal fissure
- Start Topical 3% Lidocaine Gel, apply thin film 1-2 times daily as needed.
- Educate parents on giving sitz bath
#Constipation
- Start MiraLax Powder, 17 GM/Scoop, 1 scoop mixed with 8 ounces of fluid,Orally,Once a day, 10 days.
# Annual Exam
- CBC w/o Differential
- CMP
