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Case Conference

Case Conference. February 1, 2011 Geronimo RE, Go CM, Go CK, Go F, Go MR. JOP, 4 y/o, male. CC: ANAL PRURITUS. History of Present Illness. CONSULT. Review of Systems. General: No fever, no weight loss Skin: No rashes Respiratory: No dyspnea , no cough Cardiovascular: No chest pain

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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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