Presented by Brandon Cheppa, MD
Chief Complaint: Bleeding per rectum
HPI: 5-year-old is brought in by his mother because of blood in his stool. She noticed it earlier this morning after her son had a bowel movement. The blood is bright red and streaked along the side of his feces, which are hard and brown. He is passing less stool than usual, having 1 bowel movement per day instead of 3. He has a “burning” anal pain every time he has a bowel movement. The patient does not want to eat because he is afraid to have a bowel movement, and he displays a posture to avoid putting weight on his buttocks. He denies any fever, vomiting, diarrhea, trauma, or any similar prior history.
ROS: As per HPI
Immunizations: Up to date
Family History: None
Social History: None
Examination of organ systems and body areas:
Vitals: HR: 84 RR: 18 T: 37.1 (Temporal)
General: Patient is active, playful, smiling, appearing well-hydrated. He is standing and anxious about anyone touching him.
Head: Normal scalp.
Ears: Normal tympanic membranes.
Eyes: Normal eyes. Normal conjunctivae.
Nose: Moist mucous membranes.
Neck: Supple. No lymphadenopathy.
Chest: Good air entry bilaterally. No added sounds. No retractions, or wheezing.
Cardiovascular: Good peripheral pulses. Normal heart sounds.
Abdomen: Flat, soft, nontender, Bowel sounds positive. No organomegaly.
Extremities: Nontender. No bruising. No swelling. Normal tone.
Skin: No rash.
Neurologic: Normal reflexes. No meningeal signs.
Genitourinary: External genitalia, normal male genitalia. Bilateral descended testes. No hernia.
Rectal: An examination shows a fissure at 12 o’clock and 7 o’clock. There was hard stool in the vault and the stool was guaiac negative. The anus was tender on digital exam.
1. When is an anal fissure considered chronic?
A. 2 weeks
B. 4 weeks
C. 6 weeks
D. 8 weeks
E. 10 weeks
2. Where is the most common location for an anal fissure in both males and females regardless of age?
A. anterior midline
B. anterior-lateral area
C. lateral line
D. posterior midline
E. posterior-lateral area
3. What is the most common cause of rectal bleeding in infancy?
A. anal fissure
B. infectious diarrhea
D. Meckel’s diverticulum
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