O.C.R.

O.C.M. 
This is a case of a 7-month old female from    

Apas, Lahug, admitted for constipation Prenatal: unremarkable Natal history: unremarkable Postnatal history: unremarkable Immunization: Immunization: BCG x 1 dose, DTP x 2 doses, OPV x 3 doses, Hepatitis B x 2 doses, Pneumococcal x 3, Flu x 1

O.C.M. 
Hospitalizations: none  Heredofamilial diseases: hypertension

O. with no associated fever or vomiting .C.  Chief Complaint: constipation HPI:  Two weeks PTA: patient has been having decreased frequency in bowel movement with minimal amount of solid stools which was yellow-orange in color.M.

no improvement was noted prompting mother to bring the patient for consult at the ER of this institution.O.  A week PTA. . prescribed with laxative and lactose-free milk formula.  No consult was done. mother opted to observe patient and began adding mashed papaya during feeding and two teaspoons of castor oil twice a day.M.C.

patient was noted to have decreased appetite.  Two days prior to admission.C.M. irritable and with episodes of straining that prompted consult with pediatrician.  Xray of the abdomen: non-specific and nonobstructive bowel gas pattern and fecal stasis in the ascending and transverse colonic segments .O.

 Patient was then referred to a gastroenterologist who advised them admission.C.M.O. .

O.M. warm with good turgor  BP=90/60 mmHg .C.  Physical Examination  Vital Signs: HR= 100 bpm RR=38 cpm T= 37rC Wt= 7.7 kg (P-50) Ht= 70 cm (P-90) Skin: brown. no lesions.

dry lips. non-erythematous ear canals with intact tympanic membranes. non-erythematous and unenlarged tonsils  Chest and Lungs: equal chest expansion.C. no lesions seen in buccal mucosa. regular rate and rhythm.O. no nasal secretions.M. no murmurs .  HEENT: anictericsclerae. pinkish palpebral conjunctivae. clear breath sounds  Cardiovascular system: distinct heart sounds. moist tongue.

C. no discharges Rectal Exam: skin tag at 12 o clock position. CRT < 2 seconds CNS: GCS 11 (E4V3M4) Mental status: alert .      hypoactive bowel sounds GUT: grossly female.M.O. tympanitic. admits tip of 5th digit. not distended. no stool on examining finger Extremities: full strong pulses.  Abdomen: globular.

able to swallow . full EOM  V: (+) corneal reflex  VII: no facial asymmetry  VIII: not assessed  IX & X: (+) gag reflex. VI: pupils equally reactive.O.M. IV.C.  Cranial Nerves:  I and II: not assessed  III.

 XI: not assessed  XII: tongue at midline on protrusion  Sensory: light touch.M. pain and temperature intact  Motor: spontaneous movements noted in bilateral upper and lower extremities  Reflexes: +2 in both upper and lower extremities .O.C.

 Fundoscopy: not done  Meningeal signs: none  Primitive Reflex: (+) grasp and rooting reflexes  Admitting Impression: R/I Ileusvs Large Bowel Obstruction .C.O.M.

O.  Course in the Wards:  On admission.4). serum creatinine (0.4 mg/dl).M.9 meq/L). venoclysis was started and diagnostics done include CBC which revealed leukocytosis (24. serum potassium (3. SGPT (26 mg/dl) and bleeding parameters were all within normal values.C. CRP. .

Wbc Hb Hct CBC 24.4 Plt Neu Lym Mon Eos Bas 561 39.O.C.5 3.4 12.7 4.2 .7 51.M.9 0.6 38.

.C. Patient was able to move her bowel consisting of non-bloody. yellow-green soft stools.O. nonmucoid.M.  Patient was given castor oil 10 ml every 6 hours as bowel preparation for colonoscopy the following day.

M.  On 1st hospital day.9 mkD) was started post-colonoscopy. patient underwent colonoscopy.C.O. pinpoint lesions were seen and biopsy specimen were taken.  At 35 cm from the anal verge. . IV Cefuroxime (AD= 64. Skin tags at 12 o clock position was noted. and a tight stenotic anal opening with limitation was noted during rectal exam and on insertion of the scope.

M.C. .O.

C.O. .M.

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1 36.4).6 38. No rectal bleeding and no recurrence of constipation were noted.7 from 24.4 12.C. repeat CBC was done which showed a decrease in leukocyte count (16.9 3.O.4 561 39.1 51.4 0.7 4.2 0.M.5 4/28 16.7 51.5 393 37.8 3.8 . CBC Wbc Hb Hct Plt Neu Lym Mon Eos Bas 4/26 24.9 6.7 12.  On 2nd hospital day.

7 37.9 12 36 561 393 398 39.O.1 54.9 from 16.1 51.4 11.5 3.7).2 0.6 38.8 4 3. another repeat CBC was done revealing further decrease in leukocyte count (12. Patient regained her appetite.3 4.  On 3rd hospital day.9 30.1 36.C.2 0.7 51. CBC Wbc Hb Hct Plt Neu Lym Mon Eos Bas 4/26 24.M.7 12.4 4/28 16.4 12. was no longer irritable and had no episodes of straining on bowel movement.4 .9 6.5 4/29 12.8 0.

Rectosigmoid Area  Anal Stenosis Biopsy: Chronic Non-Specific Colitis with Erosions . Final Diagnosis:  Colitis Probably Infectious.C.O.  Patient was discharged improved on the 4th hospital day.M.

closure. and limb abnormalities) . esophageal. or constriction of the rectum or anus -usually diagnosed shortly after delivery . trachea. renal. cardiac.Anal Stenosis  Anal Stenosis/Atresia -the absence. anal. often associated with a group of defects called the VACTERL syndrome (vertebral.

Anal Stenosis -can also be associated with chromosomal abnormalities. particularly trisomy 21  Demographic and Risk Factors -race/ethnicity: higher among Europeans and South Asians -maternal age: advanced maternal age associated with increased risk of chromosomal abnormalities .

Increased risk with prematurity.Anal Stenosis  Demographic and Risk Factors (continued) .Maternal diabetes: may increase risk . .Infant sex: more common among males .First trimester maternal exposure to lorazepam does increase the risk for anal atresia . lower birth weight.

04 and 7. Fecal Incontinence 3.Anal Stenosis  Prevalence: .89 per 10. Constipation 2. Abdominal distention 4.United States: ranges between 1. Rectal Bleeding .000 live births  Common Presenting Symptoms: 1.

Anal Stenosis  Diagnosis Physical Examination: .presence of an obstructive skin .

Anal Stenosis .

 The normal passage of meconium and stools is not a reliable guide to the state of the anus A stenosed anus will often allow meconium and soft stool of the newborn to escape. a rectal thermometer can also be accomodated .Anal Stenosis  The anus can look perfectly normal and yet be severely stenosed.

MRI 4. CT Scan 3. Ultrasound . Barium enema 2.Anal Stenosis  Rectal Examination: -note the size of the anus -suppleness or rigidity of the canal  Imaging: 1.

Anal Stenosis .

Surgical.high fiber diet and laxatives .Anal Stenosis  Treatment: 1. Supportive.with the use of anorectal dilators 2.

Anal Stenosis .

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