Source- Pt and Mom

S: 10 yo male with PMH of chronic constipation c/o of dizziness and fatigue yesterday after large rectal bleed 1 month ago. Pt reports having lifelong constipation and presented to PP one month ago for an anal fissure and was put on Miralax. Pt reports the next day he had diarrhea and there was a large amount of bright red blood in the toilet bowl. Pt reports LOC that day which mother reports lasted a few seconds (denied hitting his head). Pt reports his bowel movements have since improved and he is going with ease 5x/ week, with no mucous/ blood in the stool. Pt reports dyspnea and weakness yesterday when riding his bike, which was alleviated when drinking water. Pt also reports bilateral shin pain when playing. Denies n/v/d/abdominal pain/ fever/ changes in appetite/ fluid intake/ recent travel. Last GI visit was several years ago for stool withholding.

I should have asked about weight loss.

PSH: none

Medications: Miralax

Allergies: Augmentin

FamHx: Mother and twin brother have IDA; maternal grandfather has colon cancer

O:

T: 98 F
weight: 62 lb

General- Well-groomed and in no apparent distress. AOx3.

Skin- pink, no rashes/ pigmentations/petechiae/ infections

Head- normocephalic, atraumatic. Hair texture and distribution wnl.

Ears- Canals clear, TM’s and pinna wnl.

Mouth/ Throat- Pharynx/ tonsils/ uvula/soft palate/ tongue/gums wnl

Neck- supple, trachea midline. Thyroid wnl.

Nodes- cervical/ epitrochlear/ axillary/femoral wnl.

Thorax- lungs CTA. No retractions or accessory muscle use

Heart- RRR. No murmurs. S1 and S2 normal. No gallops/murmurs/rubs.

Abdomen- soft, nontender, nondistended. BS present in all 4 quadrants. No hepatosplenomegaly, hernias, CVA tenderness

Extremities- full ROM, normal muscle tone and strength, no clubbing/ cyanosis. No tenderness to palpation, including on shins.

Back/ spine- straight with full ROM.

Rectal- Healing fissure at 6 o’clock.

Psych- mood/ affect/ memory/ judgement wnl

CBC: WBC 7.5, Hb 8.9, Plts 433

 

Assessment: 10 yo male with hx of anal fissure and constipation c/o of dizziness and weakness after one episode of rectal bleeding/ LOC one month ago. CBC consistent with anemia, awaiting further workup to determine cause.

 

Plan:

• Order CBC with differential, CMP, Iron studies, hemoglobin electrophoresis, ESR/CRP, ASCA; Refer to GI pending results
• Iron supplementation- Ferrous sulfate 3 mg/kg PO, once daily.
• Continue Miralax use.
• Instruct to callback if any incidents of rectal bleeding/ syncope.
• Hold off on approving camp participation pending results
• Avoid heavy exertion. Parents should monitor patient while playing.

Differentials:

1. Meckel’s diverticulum- consistent with constipation, anemia, and one episode of sudden, profuse bleeding that resolves spontaneously. Confirm with Meckel scan (GI consult).
2. Ulcerative colitis- consistent with anal fissure, fatigue, grossly bloody stool, and anemia. Inconsistent with long standing constipation. R/o with colonoscopy (GI).
3. Colon polyps- consistent with bright red hematochezia, anemia. R/o with colonoscopy (GI).
4. Large anal fissure and resultant bleed- Consistent with confirmed presence of anal fissure. Less likely because of large amount of blood in bowl. Family hx of low hemoglobin may account for anemia. Diagnosis of exclusion, monitor for repeat events.
5. Crohn’s disease- Consistent with fissure and anemia. Unlikely because no abdominal pain, chronic watery diarrhea.

 

 

Source-Pt

 

S- 18 yo female with PMH of appendectomy, recurrent sinus infections, and seasonal allergies presents for headache for one week. Pt reports she woke up last Wednesday with a headache and nausea and has had these symptoms practically daily since. Pt reports the pain is 6/10, pressure-like, non-radiating, and located at the in the frontal and temporal region, including over the frontal sinus. She reports she usually gets the headaches in the morning and they last all day, and she will eventually get one at night if not in the morning. Pt reports it is worsened with being in the sun and alleviated with Tylenol and Advil. She reports she had finished her period a few days prior and these symptoms are inconsistent with menstruation or even her sinus infections but she does get headaches with seasonal allergies. Pt also reports a superimposed episode of diarrhea, chills, and abdominal pain on Saturday, which she attributes to food poisoning from some cheese the day before. Pt denies fever, vomiting, dyspnea, LOC, history of migraines, recent travel.

 

PSH- appendectomy

Medications- none

Allergies- seasonal allergies only. NKDA.

 

O-

T-97 F

BP-110/60

Wt-125 lb

 

General- Well-groomed and in no apparent distress. AOx3.

Skin- pink, no rashes/ pigmentations/petechiae/ infections

Head- normocephalic, atraumatic. Hair texture and distribution wnl.

Sinuses- pain with palpation over maxillary sinus only.

Eyes- PERRL, EOMI, conjunctiva clear, red reflex intact

Ears- Canals clear, TM’s and pinna wnl.

Nose- Turbinates enlarged bilaterally. Septum normal. No discharge or deformities.

Mouth/ Throat- Pharynx/ tonsils/ uvula/soft palate/ tongue/gums wnl

Neck- supple, trachea midline. Thyroid wnl.

Nodes- cervical/ epitrochlear/ axillary/femoral wnl..

Thorax- lungs CTA. No retractions or accessory muscle use

Heart- RRR. No murmurs. S1 and S2 normal. No gallops/murmurs/rubs.

Abdomen- soft, nontender, nondistended. BS present in all 4 quadrants. No hepatosplenomegaly, hernias, CVA tenderness

NEUROLOGIC

-Mental Status: Awake & Alert; oriented to person, place & time

-Cranial Nerves:

II: Visual Acuity- 20/20 with pocket screener, both eyes; Visual Fields- intact in all fields

II and III: Pupillary Reaction to Light- direct & consensual nl;  Accommodation- nl

(Can say PERRLA, pupils, equal, round, reactive to light, and accommodation for both)

III, IV, VI: EOM- intact

V: Light Touch Face- nl in all 3 divisions of V

VII: Wrinkle Forehead, Close Eyes, Show Teeth- nl

VIII: Hearing- nl by rough testing

X: Cough- nl

XI: Shrug Shoulders and check sternocleidomastoid muscles – nl

XII: Protrude Tongue- midline protrusion

-Motor System:  Normal tone

-5 / 5 strength in all extremities

-Sensory:  Light Touch- nl

– Position Sense- nl

– Vibration- nl

-Sharp- nl

– Coordination:  Gait and Balance- nl

– Finger to Nose- nl

– Tandem Walking- nl

– Romberg- negative

Reflexes not tested.

Psych- mood/ affect/ memory/ judgement wnl

 

Assessment- 18 yo female w/ PMH of appendectomy, recurrent sinus infections, and seasonal allergies, presents with consistent with seasonal allergies. Continue workup to rule out other causes.

 

Plan-

1. Order CBC, CMP, thyroid function tests, Lyme titer
2. Take Zyrtec PO (Cetirizine HCl) 10 mg once daily everyday, even if not symptomatic until allergy season subsides.
3. Take Flonase (Fluticasone propionate) 2 puffs once a day prn.
4. Advise pt to stay hydrated to avoid worsening of headaches, and consider using a humidifier at night.
5. Advise pt to consider Trumemba vaccine as she is going to college this year.

 

Differentials-

1. Seasonal allergies- consistent with past symptoms during allergy season and swollen turbinates. Confirm with improvement on Cetirizine and Flonase.
2. Tension headache from stress- Consistent with acute nature of only one week during a time of considerable current events as well as college coming up.
3. Sinus infection- Consistent with frontal sinus that is tender to palpation and pressure-like pain. Unlikely because pt reports this is inconsistent with her usual sinus infections.
4. Migraines- consistent with daily headaches that are worse with light. Unlikely because pt has no hx of migraines and the pain is non-pulsating.
5. Menstrual symptoms- Pt reports having her period during the symptoms but is unlikely as symptoms persist despite menstruation ending on Sunday.

 

 

Source-Pt

 

S- 12 yo female with no significant PMH presents with left ear pain x 3 days. Pt reports that she has been in the pool frequently and reports sharp, 4/10 left ear pain that occurs only with pressure, such as when lying on her left side. Pt reports pain in the canal as well as the pinna itself and denies any alleviating factors/ taking anything for the pain. Pt denies hx of ear infections/ f/n/v/d/SOB/chills/ recent travel/ recent illnesses/ sick contacts/ changes in hearing.

 

Surgical history- none

Medications- none

Allergies- none

 

O-

Wt-100 lb

T- 97.6 F

 

General- Well-groomed and in no apparent distress. AOx3.

Skin- pink, no rashes/ pigmentations/petechiae/ infections

Head- normocephalic, atraumatic. Hair texture and distribution wnl.

Eyes- PERRL, EOMI, conjunctiva clear, red reflex intact

Ears- Left canal inflamed and swollen. Pain with palpation of tragus and pinna. TM’s wnl.

Nose- septum and turbinates wnl. No discharge or deformities.

Mouth/ Throat- Pharynx/ tonsils/ uvula/soft palate/ tongue/gums wnl

Neck- supple, trachea midline. Thyroid wnl.

Nodes- cervical/ epitrochlear/ axillary/femoral wnl..

Thorax- lungs CTA. No retractions or accessory muscle use

Heart- RRR. No murmurs. S1 and S2 normal. No gallops/murmurs/rubs.

Abdomen- soft, nontender, nondistended. BS present in all 4 quadrants. No hepatosplenomegaly, hernias, CVA tenderness

Psych- mood/ affect/ memory/ judgement wnl

 

Assessment- 12 yo with no PMH presents left ear pain, consistent with acute otitis externa.

 

Plan-

1. Ciprodex (ciprofloxacin 0.3% and dexamethasone 0.1%) 4 drops into affected ear BID.
2. Avoid pool for few days until infection subsides.
3. Advise pt to consider buying swim headband to prevent recurrence.

 

 

Differentials-

1. Acute otitis externa- consistent with inflamed canal and tragus and pinna tenderness.
2. Acute otitis media- inconsistent with normal TM and inflamed auditory canal.
3. Foreign body- unlikely because not visualized on exam and because of patient’s age.
4. Atopic dermatitis- unlikely as it would not cause swelling of the canal and no eczematous lesions noted on exam/ no history of eczema.
5. Otomycosis- inconsistent with finding on PE and history of swimming.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This article found that 0.2% nitroglycerin ointment was effective in resolving anal fissures and  associated symptoms in younger pediatric patients. Nitroglycerin helps with anal fissures as it relaxes the internal anal sphincter, maintains the sphincter at a lower resting pressure than usual, and increases perfusion to the anal mucosa, as well as treats pain resulting from spasm of the sphincter.  The sample size included 105 patients between the ages of 4 months and 5 years, with 70 in the control group, and 35 in the treatment group. Both groups had a regimen of Sitz baths, stool softeners, and local anesthetic, with the control group also being advised to apply the 2% nitroglycerin ointment endoanally twice daily for 8 weeks (12 hours apart). The treatment group had a rate of 77% of symptom resolution and 60% healed fissure, whereas the control group had 54% symptom relief and 32.8% healed fissure, a significant difference. The study was able to avoid a high rate of headache reported in other studies, by advising endoanal application, which causes the nitroglycerin to go through first pass metabolism. No severe adverse effects were reported, however common complaints include “perianal erythema, colicky abdominal pain, and unexplained crying or nervousness” (Joda & Al-Mayoof). Negative aspects of this treatment include tachyphylaxis which necessitates constant dose increases in some patients, as well as, irritation to the site in three patients, which is thought to be the result of increased soiling from sphincter relaxation or from the ointment itself.  Other concerns include that the long treatment time and invasive application may limit compliance.