Pt Initials: EM 14yo female ADX: perianal pain …
Pt Initials: EM 14yo female ADX: perianal pain HPI:Patient presented to ED on 6/19/2016 for perianal pain reporting pain 9 out of 10 for 2.5 wks. Upon examination EM presented with exacerbated rectal fissures with open blisters, bleeding and erythema in the surrounding perianal area. She has a long-standing history of atypical IBD complications to include anal structures, inflamed rectosigmoid and rectal structure. Last week she was prescribed PRN steroids but reported that they were not helping. In 2015 an ileoscopy/EGD was performed and revealed normal results. The decision has yet to be made whether to create a permanent ileostomy vs maintaining therapy in an effort to regain integrity of a complete GI system.
Vitals: HR 78, T 36.3, Resp 16, BP 106/62, O2 98% on Rm Air