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Max King
4yo
40 Ib
CC: leaking stool in his underwear
Graded Approach Question
How can | help him today?
Does he have any other & Assoc Sx | symptoms or concerns we should discuss? (witness)
Assoc Sx | Has he lost weight? (witness)
Does he have nausea and/or Assoc Sx vomiting? (witness)
Is there any blood in his stools el Assoc Sx | or with his bowel movement? (witness)
® How^ many^ bowel^ movements Assoc Sx does he have aday? (witness)
Has he had any more stress in X Etiology s lifelately? (witness)
AN NN AAAMTMN £ 2l _ 1 1M
Information Response Obtained Clinic Notes
My son has been soiling his underwear for the past three weeks on and off despite being potty trained. It looks like streaks of watery poop. He says it just comes out and that he can’t stop it.
He’s complained of abdominal pain on and off for the last two years. It seems to start after he eats but usually goes away after a few minutes. He also complains of pain when he poops over the past two years; his mother and | have noticed that his stools are small and look hard, like little pebbles. No.
Nope.
No.
He has a bowel movement every 4-5 days, and the stools are hard and small, like little pebbles. Now he's been leaking stool in his underwear too.
His mother and | are getting a divorce. | guess that could be stressful but he's been acting normally other than this poop problem.
Graded
Graded
Approach Question Response Obtained Clinic Notes
Onset
Location Duration
Characteristics Does he have to strain when Yes. It's hard to watch defecating? (witness) sometimes.
Aggravating
. Is his pain relieved after a bowel. Relieving movement? (witness) | think so..when he has one. . About five days ago, it was a Timing/Treatments :InV:::r:;st”hl(?Nli?:;:s%wel hard stool...but he's also been ’ leaking stool.
Severity HPI
Information Approach Question Response Obtained Clinic
Is he taking any prescription FMH medications? (witness)
Can you tell me about any PMH current or past medical problems he has had? (witness)
Is he taking any over-the- PMH counter or herbal medications? (witness) PMH Do_es he have any allergies?ies? (witness)
Can you tell me about his diet? SH What does he normally eat? (witness)
Notes
Nope.
Besides what I've told you, he hasn't had any problems.
Nope.
No.
He eats three meals a day but he’s a picky eater. We can't get him to eat any vegetables. He mostly eats chicken nuggets and pizza. He loves fried foods and treats. He likes milk too, we give him about 4-5 cups a day. We tried cutting back but he refuses to drink water and we don’t want him getting dehydrated.
Feedback
Leaking stool in his underwear for 3 weeks: Since this is the most distressing symptom for this
patient and his parents and because it is highly indicative of likely diagnoses, is the most significant
active problem (MSAP).
Hard stool x 2 years, intermittent abdominal pain x 2 years: Hard, small stools occurring for 2
years with intermittent abdominal pain also occurring for 2 years indicates more chronic and less
emergent diagnoses should rise to the top of the differential diagnosis list.
Poor diet, parents getting a divorce: Lack of vegetable/fiber consumption and presence of
emotional stress are important causative factors for abdominal disease in children. As such, they are
key points in the construction and ordering of the differential diagnosis list.
Normal growth: This finding would be reassuring that this patient’s constipation is less likely due to
an organic cause, and is more likely related to functional constipation. This is an important pertinent negative and is related to the MSAP.
Diffuse abdominal tenderness to palpation without guarding or rebound tenderness: This
finding correlates with the history findings mentioned above. The lack of localized tenderness and the
lack of red flags like guarding and rebound tenderness help confirm the pivot towards more chronic
and less emergent diagnoses on the differential diagnosis list.
Case Problem Statement
This patient is a 4 yo male who has had intermittent abdominal pain after eating and hard stools
for the last two years. He has been stooling every 4-5 days and his father states that it is 'like
pebbles'. For the past three weeks, he has been leaking stool in his underwear. His father state
that the patient tells him that he "can't help it" and "it just comes out." He has had poor dietary
habits and his parents are divorcing. Physical examination shows stable vitals and diffuse
abdominal tenderness to palpation without guarding or rebound tenderness.
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Your Differential Diagnoses
Legend: @ Correct X Missed
@ encopresis
@ hypothyroidism
@ gluten-sensitive enteropathy (celiac disease)
X congenital aganglionic megacolon (Hirschsprung's disease)
X constipation
Feedback
® Correct
1. encopresis
2. hypothyroidism
3. gluten-sensitive enteropathy (celiac disease)
Your Your Your
Differential Diagnosis Lead Graded Alt Graded MNM Graded
congenital aganglionic megacolon
(Hirschsprung's disease) o ©. €
constipation © ® [ J O
encopresis O] ® (o]
gluten-sensitive enteropathy (celiac disease) O ® [ J
hypothyroidism (0] ® ®
Feedback
The following information addresses lead and must-not-miss designations in the differential diagnosis
list:
Encopresis: This diagnosis fits all key findings listed and so is the /ead diagnosis for this case. It
outranks constipation because constipation is a causative factor for encopresis and constipation
alone does not account for all key findings.
For this case, there is no must-not-miss diagnosis, because it is unlikely that any condition he has or
could develop over the next 24-48 hours would be a life-threatening condition. If this patient was a
neonate, Hirschsprung's disease would count as a surgical emergency. A partial aganglionic colon
can present later in life, around 3-4 years old, and can be scheduled for elective surgery.
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Plan Feedback
Pharmacologic Care:
« Initial cleanout dosing: Give polyethylene glycol (PEG) 3350 17 g/dose, 1 dose mixed in 6-80z of water or juice over 3 hours.
« If no response, repeat the same dose tomorrow.
« Maintenance dosing: Give polyethylene glycol (PEG) 3350 17g/dose, 1/2 dose mixed in 6-8 oz water
or juice daily.
Supportive Care:
Increase fiber intake. l
Increase fluid intake. Decrease milk consumption; may be able to do this by watering down milk. Encourage at least a moderate amount of physical activity daily. Have the patient sit on the toilet and attempt to have a bowel movement for 5-10 minutes at the same time of day, every day.
Patient Education:
Educated family on functional constipation and how it can lead to encopresis. Educated family on pharmacologic and nonpharmacologic therapy to treat constipation, such as changes in diet, regular toileting times, and osmotic laxatives. Discussed red flag symptoms, such as increased abdominal pain, vomiting, and fever. Referral to nutritionist provided.
Follow-Up:
« Follow up in 2 weeks for re-evaluation. « Follow up sooner if no improvement after 2 days of the cleanout regimen or if there is no improvement with maintenance therapy. « Call the office or go to ED for fever, uncontrolled vomiting, increase in pain, or other concerning
symptoms.
« Maintain previously scheduled 4-year-old well-child visit for routine vaccinations and anticipatory guidance.
