rectal itching/pinworms

var dngJsonData = {“HPI”: [{“textArea” : {“sentence” : “{ENTRY}”,”label” : “HPI”,”value” : “Patient is here for possible pinworms. Patient witnessed some small worms on the stool yesterday upon wiping after BM. Itchiness around the anal area is worse in the evening. Denies fevers, chills, abdominal pain, diarrhea. Did the scotch tape test last night and found worms. ”}},{“textArea” : {“sentence” : “Review of Symptoms: {ENTRY}”,”label” : “Review of Systems”,”value” : “

Review of Systems: ”}}],”Body”: [{“textArea” : {“sentence” : “{ENTRY}”,”label” : “Physical Exam:”,”value” : “Constitutional: Well-nourished, and in no distress. No distress. HENT: Right Ear: Hearing, tympanic membrane and ear canal normal. Left Ear: Hearing, tympanic membrane and ear canal normal. Pulmonary/Chest: Effort normal. Neurological: alert and oriented Skin: Skin is warm and dry. Multiple small superficial anal fissures and mild skin breakdown around the external anus. Skin: General: Skin is dry. Findings: No rash. Nursing note and vitals reviewed.”}},{“textArea” : {“sentence” : “{ENTRY}”,”label” : “Past Medical History – Free text as needed”,”value” : “- hydrocortisone (ANUSOL-HC) 2.5 % rectal cream; Place rectally 2 (two) times a day.   MDM: Signs of mild anal fissures. No hemorrhoids, anal/rectal masses, or other notable local physical exam findings. No notable eggs or worms. His children do not have similar symptoms. We discussed the possibility of treating for pinworms again but he will check his children 1st. He was counseled on home tape test. If he is not improving as expected with topical steroids he will return. If his children develop symptoms he will have them seen by the PCP/pediatrician. If anyone in the family develops finding of pinworms whole family should be treated again”}},{“textArea” : {“sentence” : “{ENTRY}”,”label” : “Past Surgical History – Free text as needed”,”value” : “Anal itching Rectal itching, could due jokey's itch But with more itching at night time, concerning for parasites Suggest patient to do stool culture screening Also consider a scotch tape test over the anus for next 2 nights ”}},{“textArea” : {“sentence” : “{ENTRY}”,”label” : “Social History”,”value” : “Ova and parasite examination ”}},{“textArea” : {“sentence” : “{ENTRY}”,”label” : “Family History”,”value” : “mebendazole 100 mg chewable tablet (EMVERM) Disp Refills Start End albendazole (ALBENZA) 200 mg tablet 2 tablet 0 12/31/2020 1/1/2021 Sig - Route: Take 2 tablets (400 mg total) by mouth once daily for 1 day. Then repeat in 2 weeks - Oral ”}}],”MDM”: [{“textArea” : {“sentence” : “{ENTRY}”,”label” : “Medical Decision Making”,”value” : “Patient's mother comes in with obvious pinworms x3 on scotch tape. Will empirically treat with mebendazole per Up to Date recommendations. Two doses in the span of 2 weeks. Hand out given for home care. Good hand hygiene discussed. Other family members to monitor for signs and symptoms.   Pt brought in stool sample w about 50mmx1mm tubule shaped worm like object – send to lab Mebendazole Rx but recommend hold off until final diagnosis We do not have glass slides to do tape test for sendout pinworm egg exam   Unclear if anal itching related to above worm - trial of keeping area dry and barrier protection w petroleum jelly while waiting for lab result   ICD-10-CM ICD-9-CM   1. Rectal itching L29.0 698.0 C DIFF+O+P+STOOL CULTURE Patient is here with concerns of possible pinworm or other parasitic infection. Patient on exam has no signs of pinworm but with description there is concern for this. Patient is breastfeeding so I did review the SE of albendazole treatment and the importance of repeating tx in 2 weeks. Epocrates, and Up to date info read to patient in the room, patient also encouraged to speak with their Pediatrician before taking the medication. I did send stool cultures to screen for O&P that patient will return to the lab as well to determine if any other parasite is in her stool. Patient also instructed on the scotch tape testing to try at night. Patient over all given lots of pinworm education and instruction will follow up once stool cultures return. Should go to the ER if worsens before then, abdominal pain, fevers, vomiting or copious diarrhea. ”}}]}