General Data

The patient is PB, a 10 year and 6 months old female born November 17, 2010. She is Filipino,
Roman Catholic, and living in Taytay Riza. She was seen on October 11, 2021 via teleconsultation. The
patient’s informant is her sister, P, who has been assessed to have good reliability.
Chief complaint: (Follow up on) Persisting Left Popliteal and Anal Pain

History of Present Illness:

2 weeks PTC, she started to experience perianal tenderness described as sharp and stinging which she
would experience even when not passing stools, with pain scale 4-5/10. Denies any trauma to the left
popliteal area and lower extremities.

1 week PTC, patient noted Bristol type 2 stool which deviated from her normal bowel habit (Bristol type
6-7). Sought consult at The Medical City Divine Mercy OPD via teleconsultation where she was given
Paracetamol 500mg/tab, 1 tab every 8 hours as needed for moderate-severe anal pain and popliteal
pain. She was instructed to avoid strenuous activities for now and do a 1 week bowel movement diary
(describe consistency according to Bristol chart, frequency per day, associated symptoms like abdominal
pain, difficulty in passing out stool, stool clogging the toilet, blood on stools). Patient was advised to
increase oral fluid intake and limit intake of sugary drinks. Patient’s guardians were given guidelines for
anticipatory care as well. She was scheduled for follow up the next week.

In Interim, patient claims that the pain persisted in the same areas. She is noted to have 1x BM every
day or every other day, usually Bristol 2-3 in consistency (dry, lumpy) but no straining noted. 1 day prior,
noted with Bristol type 5 stools.

Day of Consult, Patient is still complaining of anal pain and left popliteal pain. The patient claims that the
pain is persistent throughout the day, aggravated when she is seated, but no pain is noted whenever she
is passing stools. The pain is said to be 5-6/10 in severity, temporarily relieved by intake of paracetamol.

Patient also notes persistent left popliteal pain, not aggravated by movement. She said that the pain is
worse when lying down, and she is still able to exercise and ambulate independently without difficulty.
Occasionally massaged when painful, pain noted to be aggravated by palpation but not by movement.
Pain is relieved temporarily with intake of pain medications (not mentioned).

Review of Systems

Constitutional: (-) weight loss, (-) Irritability

HEENT: (-) rashes, (-) lumps, (-) sores, (-) itching, (-) discoloration of hair, skin, nails, (-) edema, (-) hearing
problems, (-) ear discharge, (-) epistaxis, (-) colds, (-) nasal obstruction, (-) hoarseness, (-) dry mouth, (-)
gum bleeding, (-) tongue sores, (-) enlarged lymph nodes
Respiratory: (-) Difficulty of Breathing
Gastrointestinal: (-) nausea, (-) dysphagia
Genitourinary: (-) difficulty urinating
Musculoskeletal: (-) no joint pain
Neurological: (-) seizures, (-) tremors, (-) headaches, (-) dizziness
Past Medical History
 Patient was a known case of Retinoblastoma since February 2021, maintained on the following
medications: Levetiracetam 250 mg/tab 1 1/2 tablet in the morning and 1 1/2 tablet in the evening (8.3
mg/kg/dose); Cotrimoxazole 800 mg/160 mg/tab twice daily during Mondays, Wednesdays, and Fridays;
Vitamin E (Myra E) 400 mg/tab 1 tablet once a day . Patient had undergone 4 cycles of Chemotherapy
(Last was June 2021) and 28 sessions of Radiotherapy (Last was October 5, 2021). She was admitted in
the hospital for chemotherapy on these dates: February 2021, April 5, and April 26, 2021, and (last date
not reported).

She has history of surgery, with Enucleation of the left eye in November 2019, done in The
Medical City. Patient also has history of accidental left eye trauma from a pencil at school (2017). There
was no noted visual changes, discharge, or pain noted, so no consult was done at that time. Patient has
history of Animal bite via dog (year not reported), category II, for which she was given post-Rabies
vaccination (3 doses). Other than the mentioned, patient has no other illnesses or any allergies.

Maternal/Gestational and Birth History

Patient was born to term at 39 weeks AOG via normal spontaneous delivery at a Hospital with
no complications. Newborn screening and hearing tests were done with no significant findings. No
other information was given of the mother and her condition during her pregnancy with PB.

Feeding History

Patient was exclusively breastfed until 7 months of age after which complementary feeding was
done (kind of food not elicited). Patient continued this diet of breastmilk and complementary food until
1 year of age, after which she was given formula instead, amount unrecalled. Patient also started eating
rice and different viands. Patient has no known allergies to food.

Ever since the start of her chemotherapy, she has shown more preference to eating meat,
specifically pork chops and processed foods (pancit canton, hotdog) and less vegetables. She drinks
coffee and Milo once a day and would often have milk tea after her radio therapy sessions. Does not
drink soft drinks.

Developmental and Behavioral Milestones

Developmental and Behavioral Milestones were not elicited in the interview.

Immunization

PB’s first 2 years of vaccinations were allegedly completed by their local health center, however
no baby book was given to confirm. No reported recent vaccinations were given to PB as well.

Family History

The patient has a mother, father, and 3 older siblings. In order, she has an older brother (27), an
older sister (25) and a second older brother (18) all of whom are in good health. No one in the family has
the same symptoms as the patient. Father and mother has no known comorbidities however family has
a history of hypertension on the paternal side; and history of breast cancer and tuberculosis on the
maternal side. No other history of illness or chronic infectious conditions existing in their family. No one
in the family has had COVID and patient has not been exposed to any COVID-suspect or patient.
HEADSSS

HOME- Patient lives in a compound together with other households in Taytay, Rizal. She lives with her
mother and 2 of 3 of her older siblings. She is closest with her cousin who lives in a nearby compound.
She doesn’t get along well with her eldest brother.

EDUCATION- Patient is a Grade 5 student. Has been completing modules for school. Despite not having
online activities, studying during the pandemic has been difficult. The patient enjoys science the most,
generally struggles with academics, but she says her grades are okay. She has no extracurricular
activities and reports verbal bullying in school after her enucleation procedure. The patient wants to be
a doctor when she grows up.

ACTIVITIES- Patient spends her free time going on social media, doing Tiktok dances, and playing online
games. Denies any of these interrupting her sleep patterns.

DRUGS- Denies exposure to any drugs, smoking, or illicit substances

SEXUALITY- The patient has crushes from the opposite sex (BTS). No noted intimate relationships or
sexual activities.

SUICIDALITY- The patient is reportedly bored at home but finds strength through overcoming her
current condition through her religion (Inglesia ni Cristo)

SAFETY- The patient reports no fears for safety, lives in a compound with her relatives, and is driven
around by her relatives whenever she needs to go out.

Gynecologic

Patient started her menstrual period at 9 years old. Reported had regular intervals before her
chemotherapy and radiotherapy, lasting about 2 to 3 days. She uses 1 to 4 moderately soaked pads with
no dysmenorrhea and other associated symptoms during that period.

Stakeholder’s Analysis

Stakeholders Analysis was not elicited in the interview.

OBJECTIVE

Physical Examination

 Vital Signs were not taken during the teleconsultation

 Anthropometrics noted: Weight 47.3 kg; Height 143 cm; BMI 23.13

Patient was awake, alert, and oriented. Eye exam showed pink palpebral conjunctivae and anicteric
sclerae. Ear exam showed negative tragal tenderness, and no ear discharge. There was no nasal
discharge and obstruction. Her oral mucosa was moist, with no oral sores or hyperemic tonsils. No
palpable CLADS. (+) for Abdominal Striae, No abdominal pain. No limitation of movement on bilateral
knee joints, no erythema noted. No palmar pallor; CRT <2 seconds

No seen masses, lesions, deformities, or defects on the chest wall. Respirations appeared regular
and non-labored. Her abdomen is slightly globular, soft, non-tender with no visual masses. Her skin is
warm with no rash. Her back exam reveals no deformities or cutaneous defects. Skin showed normal
skin turgor and no other signs of dehydration. DRE and test for CNs were not done as it was done last
consultation which was a week ago.

Findings:
DRE - No lesions, no fissures in the perianal area; perianal tenderness (4/10 in severity); no palpable
masses, no fistulas; no blood, minimal stool on examining finger; good sphincter tone.
Cerebral - conscious, coherent, oriented to three spheres, GCS 15 (E4V5M6)
Cranial Nerves
 CN I- not assessed
 CN II- pupils 2-3 mm ERTL, normal direct and consensual pupillary reflexes, right eye
 CN III, IV, VI – EOMs intact
 CN V – no facial sensory deficits, able to chew
 CN VIII – gross hearing intact
 CN IX, X – uvula midline
 CN XI – can turn head-to-head, can shrug shoulders against resistance
 CN XII – tongue midline on protrusion
 Motor: 5/5 on both upper and lower extremities; no limitations in ROMs
 Cerebellar: (-) dysdiadochokinesia
 Sensory: 100% on both upper and lower extremities

Working Impression: Muscular Strain on the Left Popliteal Area and Functional Constipation
More likely. Symptoms seem to not be related to each other. Patient doesn’t seem to have
consistent bowel movements and she also has no pain upon strenuous activities.

Plan: Lactulose for dis-impaction and ibuprofen for pain management. Continue stool charting/diary.
Work up: Abdominal and Chest Xray to check for fecal stasis