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Esteban Soto iHuman (4 y.o with leaking stool in underwear) Does he have nausea and/or e Assoc Sx vomiting? (witness) Nope: Is there any blood in his stools or e Assoc Sx _ with his bowel movement? No. (witness) He has a bowel movement every 4- 5 days, and the stools are hard and @ Assoc Sx Sarg as does mall, like little pebbles. Now he's y been leaking stool in his underwear too. His mother and | are getting a Has he had any more stress in his J'Vorce. | guess that could be X Etiology fe lately? (witness) stressful but he's been acting ¥ normally other than this poop problem. 5 Information Obtained Graded Approach Question Response Clinic Notes My son has been soiling his underwear for the past three weeks @ ccs —_ Howcan | help him today? on and off despite being potty (witness) 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 Does he have any other symptoms _ usually goes away after a few @ Assoc Sx or concerns we should discuss? minutes. He also complains of pain (witness) when he poops over the past two years; his mother and | have noticed that his stools are small and look hard, like little pebbles. X | Assoc Sx Has he lost weight? (witness) No. Does he have to strain when defecating? (witness) Yes. It's hard to watch sometimes. @ = Characteristics Aggravating Is his pain relieved after a bowel movement? (witness) | think so..when he has one. e Relieving About five days ago, it was a hard stool...but he's also been leaking stool. When was his last bowel e Timing/Treatments movement? (witness) Esteban Soto iHuman (4 y.o with leaking stool in underwear) Is he taking any prescription e PMH medications? (witness) Nope. Can you tell me about any current @ PMH or past medical problems he has had? (witness) Besides what I've told you, he hasn't had any problems. Is he taking any over-the-counter or @ PMH herbal medications? (witness) Nope. Does he have any allergies? e PMH (witness) 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 esx Gatyourtell me abouthis die’? ayes fried foods and treats. He i pesine: nomaty:ea! likes milk too, we give him about 4- yainess} 5 cups a day. We tried cutting back but he refuses to drink water and we don't want him getting dehydrated Physical Exam Feedback @ Performed Correctly * auscultate abdomen Auscultation of the abdomen is important to assess normal GI motility. © You performed the simulation correctly. © You interpreted assessment correctly. * auscultate heart Auscultation of vital organs like the heart is always a vital part of the physical examination o You performed the simulation correctly. © You interpreted assessment correctly. * auscultate lungs Auscultation of vital organs like the lungs is always a vital part of the physical examination. Esteban Soto iHuman (4 y.o with leaking stool in underwear) 1of1 Index of Exercises @Corect Missed C Incorrect Choice Yours Graded Hard stool for 2 years e O|8 Hematuria No abdominal pain Nocturesis Parents getting a divorce Currant jelly stool Poor diet Diarrhea High fiber diet Excessive water intake BOOO8 OW oOO0 e Intermittent abdominal pain for 2 years Diffuse abdominal tenderness to palpation without guarding or rebound tenderness i<| e Coarse hair Normal growth Fatigue Fear of food Leaking stool in his underwear for 3 weeks Megacolon Anxiety Fever oooomoooo0 e Blood on underwear Esteban Soto iHuman (4 y.o with leaking stool in underwear) Case Findings Leaking stool in his underwear for 3 weeks Intermittent abdominal pain for 2 years Hard stool for 2 years Poor diet Parents getting a divorce Normal growth Diffuse abdominal tenderness to palpation without guarding or rebound tenderness 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 ‘ike pebbles’. For the past three weeks, he has been leaking stool in his underwear. His father states 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. Your Differential Diagnoses Legend: @ Correct X Missed € Extraneous @ encopresis @ constipation ® congenital aganglionic megacolon (Hirschsprung's disease) % gluten-sensitive enteropathy (celiac disease) hypothyroidism Esteban Soto iHuman (4 y.o with leaking stool in underwear) 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. * Ifno 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 * 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 
