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Performance Overview for Lauren Walls on case Esteban Soto
The following table summarizes your performance on each section of the case, whether you completed that section or not. Time spent: 3hr 23min 52sec Status: Submitted Case Section Status Your Score Time spent Performance Details Total Score 61% History Done 80% 49min 15sec 60 questions asked, 12 correct, 3 missed relative to the case's list Physical exams Done 88% 34min 47sec 38 exams performed, 10 correct, 2 partially correct, 0 missed relative to the case's list Key findings organization Done 1min 16sec 5 findings listed; 7 listed by the case Problem statement Done 3min 27sec 83 words long; the case's was 97 words Differentials Done 80% 1min 18sec 4 items in the DDx, 4 correct, 1 missed relative to the case's list Differentials ranking Done 100% (lead/alt score) 20% (must not miss score) 2min 41sec Tests Done 100% 2min 19sec 6 tests ordered, 0 correct, 0 missed relative to the case's list Diagnosis Done 100% 6sec Management plan Done 50min 7sec 734 words long; the case's was 207 words Exercises Done 82% (of scored items only) 3min 18sec 0 of 1 correct (of scored items only) 1 partially correct Attempt: 2613894 Report generated on 1/15/2023, 8:50:44 PM America/Denver
History Notecard by Lauren Walls on case Esteban Soto
Use this worksheet to organize your thoughts before developing a differential diagnosis list.
- Indicate key symptoms (Sx) you have identified from the history. Start with the patient's reason(s) for the encounter and add additional symptoms obtained from further questioning.
- Characterize the attributes of each symptom using "OLDCARTS". Capture the details in the appropriate column and row.
- Review your findings and consider possible diagnoses that may correlate with these symptoms. (Remember to consider the patient's age and risk factors.) Use your ideas to help guide your physical examination in the next section of the case.
HPI
Sx =fecal
incontinence
Sx
=abdominal
pain
Sx =hard
stools
Sx
Sx
Sx
Onset 3 weeks ago 2 years ago 2 years ago
Location abdomen
Duration 3 weeks intermittent intermittent
Characteristics watery stool pain hard
pebbles
Aggravating eating
Relieving bowel
movement
Timing /
Treatments
intermittent after meals
Severity
Attempt: 2613894 Report generated on 1/15/2023, 8:50:44 PM America/Denver
Management Plan by Lauren Walls on case Esteban Soto
Patient is a 4-year-Old Caucasian male child visited the clinic with his father with a complaint of leaking stools in his underwear for the past 3-weeks. Father states that patient had intermittent abdominal pain for 2 years and had experienced hard stools as well. He also states that his child started having watery stools, 2-3 times in a day for the past 3-weeks. Father reports that the abdominal pain usually starts after eating and gets better a few minutes. Treatment/Management Plan Primary Diagnosis: Encopresis ICD-10 code: F98. Encopresis is also called stool soiling and can been defined as an intentional or involuntary movement of stools into the underwear or clothing. The disorder is common in children 4 years and older who were previously potty trained. The disorder is caused when the child resists the urge to defecate, causing feces to become impacted in the colon. The result of the impaction is constipation, followed by leaking stools (Colombo et al., 2017). Symptoms may include sudden urge to have a bowel movement, fecal incontinence, loose stool, leakage of stool into the underwear, intermittent pain in the abdomen, constipation, and the child avoiding the act of deification. The patient presents to the clinic with most of the primary subjective and objective symptoms, making encopresis the primary diagnosis. Differential Diagnosis Constipation- ICD-10 code K59. Constipation is defined as dissatisfying excretion of feces associated with decreased occurrence of stools and/or difficult stool passage. Common clinical presentation includes reports of less than three bowel movements per week, hard stools, abdominal discomfort, abdominal pain, bloating, and increased time on toilet. Constipation was not chosen as the primary diagnosis because the patient also presents with leaking stool soiling the underwear. Celiac disease- ICD-10 code K90.0. Celica disease is a genetic autoimmune response to consuming gluten, a protein found in wheat, barely, and rye, which impacts the gut and surrounding organs (Wolters Kluwer Health., 2016). Common clinical symptoms include constipation, nausea, vomiting, diarrhea, and loss of weight. The patient in the case reports diarrhea and constipation but denies the other qualifying symptoms. Hypothyroidism- ICD-10 code E03. Hypothyroidism is defined as a disorder in which the thyroid gland does not produce sufficient thyroid hormones. Symptoms include fatigue, dry skin, and constipation. The patient in this case presents with constipation but does not have dry skin or fatigue. Hypothyroidism would not be a suitable primary diagnosis. Diagnostic Tests The primary diagnosis is made based on clinical presentation. No additional diagnostic testing is needed. Treatment Plan Pharmacological treatment MiraLAX 1.5g/kg/day, PO, daily for 3 days followed by a maintenance dose of 0.8g/g/kg/day PO daily for 6 months. Non-Pharmacological Managment *Participate in daily physical activity *Eat a diet high in fiber and fresh fruits *Consume 2000-3000 ml of fluids daily Health Promotion *Establish healthy dietary habits
*Recommend at least 30 minutes of physical activity daily *It is important to establish healthy eating patterns in early childhood, following the CDC guidelines such as "My Plate". Patient/Parent Education: *provide high fiber foods *decrease cow's milk products *increase water intake *encourage physical activity at home *do not punish child for soiling underwear, the child can not control the loose stools *use positive reinforcment techniques for successful trips to toilet and following medication plan *avoid serving foods that are fried or greasy Anticipatory Guidance
- Establish a positive, nurturing environment, and healthy patterns of feeding and eating to promote eating habits that are built on variety, balance, and moderation. *Develop problem-solving skills to be able to handle the stress that comes out from divorce so that it will not affect the child psychologically Social Determinants of Health *Provide resources to ensure access to healthy foods> *Provide resources to assist parents to provide a nurturing and low stress environment for the child during divorce. *Ensure that child feels safe at home and school. References Bianco, A., Chaker, L., Jonkklaas, J., and Peeters R. P., (2017). Hypothyroidism. Retrieved January 13,2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6619426/. Colombo, J.M., Rosen, J.M., and Wassom, M.C., (2015). Constipation and Encopresis in Childhood. Pediatrics in Review September 2015, 36 (9) 392-402. Retrieved Janaury 13, 2023, from https://pedsinreview.aappublications.org/content/36/9/ Hagan J.E, Shaw J.S, and Duncan P.M., (2019). Bright futures: Guidelines for Health Supervision of Infants, children, and Adolescents. 4th ed. ELK Grove Village, IL: American Academy of pediatrics Wolters Kluwer Health. (2016, January 19). New guidelines reverse previous recommendations on gluten introduction to prevent celiac disease. ScienceDaily. Retrieved January 13, 2023, from www.sciencedaily.com/releases/2016/01/160119142303.htm Attempt: 2613894 Report generated on 1/15/2023, 8:50:44 PM America/Denver
Social History
Category Data entered by Lauren Walls Social History lives in apartment and 2-year-old sister father denies exposure to secondhand smoke
Review of Systems
Category Data entered by Lauren Walls General denies fever, chills, fatigue or changes in appetite or weight loss/gain Integumentary / Breast no rash or injury to skin HEENT / Neck Eyes: No visual loss, blurred vision, double vision, or yellow sclerae. Cardiovascular No chest pain, chest pressure, or chest discomfort. No palpitations or edema. Respiratory No shortness of breath, cough, or sputum. Gastrointestinal No anorexia, nausea, vomiting or bloody stool. father reports patient has been having hard stools for 2 years and leaky stools x2, when having stool and has one stool every 4-5 days Genitourinary Denies changes to urinary pattern or frequency. Musculoskeletal Denies pain, weakness, or injury. Allergic / Immunologic Denies allergies to food, medications, or environment. Endocrine No reports of sweating or cold or heat intolerance. No polyuria or polydipsia. Hematologic / Lymphatic denies bleeding of gums or swelling of lymph nodes Neurologic : No headache, dizziness, syncope, paralysis, ataxia, numbness, or tingling in the extremities. Father reports loss of bowel control for 3 weeks Psychiatric : Denies changes to mood, depression, or anxiety.
Physical Exams
Category Data entered by Lauren Walls General alert and oriented x4, dressed appropriately for situation and age. Skin no rashes, lesions, or injury noted. HEENT / Neck Head normocephalic and without trauma, PERRLA. Full ROM noted, trachea is midline, no masses noted. Nares patent and without injury. Gums and teeth appear intact. Cardiovascular Regular heart rate and rhythm, no palpitations noted, no peripheral edema noted, peripheral pulses regular and strong bilaterally. Chest / Respiratory lungs are clear to auscultation in all lobes no abnormal retractions or use of accessory muscles noted Abdomen abdomen is flat and symmetric with no scars, deformities, striae or lesions. no masses felt. Diffuse tenderness to palpation of the abdomen. No guarding or rebound tenderness No hepatosplenomegaly, normal liver span, spleen is not palpable No tympany or shifting dullness Normal abdominal girth Genitourinary / Rectal Normal external genitalia no masses or tenderness. no urethral discharge testicles descended bilaterally. Normal rectal exam Musculoskeletal / Osteopathic Structural Examination Normal bulk and tone no rigidity Neurologic Alert and oriented x4, No headache noted. Psychiatric no apparent anxiety Lymphatic no swelling to lymph nodes Attempt: 2613894 Report generated on 1/15/2023, 8:50:44 PM America/Denver
