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Case Conference

This case study presents a 4-year-old male presenting with anal pruritus. The review of systems reveals no significant acute health issues, and his developmental history indicates he is on par for his age. Past medical history includes a parasitic infection at age 3. Physical examination is largely unremarkable apart from a hyperemic anal region. Management includes a scotch tape swab to confirm Enterobius vermicularis, dietary recommendations, dental referrals, and immunization updates. Follow-up scheduled to monitor treatment efficacy.

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Case Conference

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  1. Case Conference February 1, 2011 Geronimo RE, Go CM, Go CK, Go F, Go MR

  2. JOP, 4 y/o, male CC: ANAL PRURITUS

  3. History of Present Illness CONSULT

  4. Review of Systems • General: No fever, no weight loss • Skin: No rashes • Respiratory: No dyspnea, no cough • Cardiovascular: No chest pain • Gastrointestinal: No abdominal pain, no diarrhea, no constipation • Musculoskeletal: No limitation of movements • Genitourinary: No dysuria, no hematuria • Endocrine: No heat/cold intolerance • Hematologic: No bleeding tendencies • Nervous: No seizures

  5. Developmental History • At par with developmental age • Emergence of primary teeth • No incontinence, toilet trained, no head banging, phobias, night terrors, sleep disturbances

  6. 24 Hour Food Recall

  7. Recommended Energy & Nutrient Intake

  8. Immunization • Unrecalled • Claimed to be complete

  9. Past Medical History • Parasitic infection • 3 y/o • Unrecalled medication • Local health center

  10. Family Profile and History • Primary caregiver – mother • Lives with – both parents and sister • (-) HTN, DM, asthma, cancer, thyroid problems, blood dyscrasias, allergies

  11. Socioeconomic and Environmental History • House - concrete, well lit, well ventilated • Pets - 53 pigeons • There are no factories nearby • Exposed to cigarette smoke - father • Drinking water - water station • Garbage collection – 1/week, not segregated

  12. Physical Examination Awake, alert, ambulatory, not in cardiorespiratory distress, well nourished, well hydrated BP: 110/70 mmHg PR: 100 bpm RR: 26 cpm Temp: 36.5 C Wt: 15.9kg ( 0 = normal) Ht: 103cm (above +3 = tall) BMI: 17 (below -1 = normal) Wt for ht: z score: 0 (normal)

  13. Physical Examination • Warm, moist, good turgor, no blanching, no petichae, no rashes, no active dermatoses • Normocephalic, black hair, fine texture, no nits/lice • Pink palpebral conjunctiva, pupils 3-4 mm ERTL, EOMs full and equal

  14. Physical Examination • No tragal tenderness, no aural discharge, (+) retained cerumen AU, nonhyperemic external auditory canal, tympanic membrane intact • Nasal septum midline, no nasal discharge,non hyperemic nasal mucosa, turbinates not congested, (+) nasal discharge • Moist buccal mucosa, no lesions, non hyperemic posterior pharyngeal wall, tonsils not enlarged, (+) dental carries

  15. Physical Examination • Supple neck, no palpable cervical lymph nodes, thyroid gland not enlarged • Symmetrical chest expansion, no retractions, clear breath sounds • Adynamicprecordium, apex beat at the 5th LICS MCL, no murmurs • Flabby abdomen, normoactive bowel sounds, soft, no masses, no tenderness • Pulses full & equal, capillary refill <2 sec, no cyanosis, no edema • (+) hyperemic anal region

  16. Assessment • t/c Enterobiasis, dental carries

  17. Management Done • For scotch tape swab • Diet for age • Refer to dental services • Multivitamins 5ml once a day • Update immunizations (BCG booster) • Anticipatory guidance • TCB w/ results

  18. Follow up (after 6 days) • Scotch tape swab – positive for enterobiusvermicularis ova • Assessment – EnterobiusVermicularis Parasitism • Plans – Praziquantelpamoate 125mg/5ml, give 7 ml once then after 2 weeks

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