Patient Information: A.B., 5/yo, Male, African American
Subjective:
CC :” Bottom itches”
HPI: A.B. is a 5-year-old AA male who presented to the
... [Show More] clinic with itching around his anal area
that began about 4 weeks ago and has increased in severity. He is a kindergarten student and his
mother reports that the anal itching is moderate. He also has irritation and anal leakage requiring
the use of pull-ups at night. It is also reported that the itching has caused difficulty sleeping at
night and he awakens multiple times. He has a history of constipation and recently had a change
in bowel habits. His mother states he normally has bowel movements daily but in the last 4
weeks since he began school he only has a bowel movement 1-2 times a week. It is reported he
bites his nails and has poor hand hygiene following the use of the toilet and before meals. His
mother also states that he has started the use of a new bubble bath soap and she has used a new
laundry detergent to attempt the decrease the itching. No other symptoms were reported and his
mother states no other treatment for the itching has been utilized.
Current Medications: Children’s multivitamin 1 tablet daily
Allergies: No allergies reported
Pertinent PMHx: Patient is in general good health. History of chronic constipation started after
breast feeding was stopped, worsened during potty training. Still continues to have episodes
during times of stress and changes such as vacation.
Medical, surgical, obstetric, hospitalizations:
In utero ultrasounds were reported normal without developmental defects.
Gestational history unremarkable.
Patient was a full term vaginal delivery; birth weight was 7 pounds 15 ounces.
Patient was discharged from the hospital one day after delivery with mother.
No other hospitalizations, surgeries, ER visits, or specialist provider visits.
Vaccinations:
Hepatitis B given:
at birth
at 2 months old
at 6 months old
at 12 months old
Oral rotavirus series given: [Show Less]