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MAX KING LEAKING STOOL iHUMAN CASE
STUDY SOLUTION
Graded Approach Question ' Response
Information Obtained Clinic
Notes
cc Assoc Assoc sx can help him today? Does he have •any other symptoms or concerns we should disr:u«? (witness) Has he lost weight? (witness) Does he have nausea and/or vomiting? (witness) My son has been soiling his underwear for the past three weeks on and Oft despite being potty trained, It looks like streaks of watery poop. He says it just comes out and that can 't stop O it- HSS complained of abdominal pam on and for the ;tast two years. It seems to start after he oats but usually goes away after a tow minutes. He also complains Of pain when he poops over the past two years; his mother and have noticed that stools are small and look hard, like little Assoc sx
Assoc
Is there any blood in his stools or with his bowel movement? (witness) How many movements dogs he have day? (witness) No. He has a bowel movement every 4-5 days. and the stools are hãrd arid small, like little pebbles. Now he's been leaking in his underwear too.
NURSING EXAM SOLUTION I VERIFIED CLINICAL ANSWERS Max King 40 1b CC: leaking stool in his underwear X Etiology^ Has he had any more stress in his lite lately? (witness) His mother and I are getting a divorce. I guess that could be stressful but been acting normally Other than this poop problem.
Name: Max
King Age: 4
sex: M
Weight: 40 1b
BMI: 175
Cognitive status: A and O x 4
Temp: 37.OOC (98.6 (oral) pulse: 84 bpm, rhythm: regular. strength: normal left: t 00/60, right: 102/62. assessment: normotensive, pulse pressure: normal Respiration: 22 bpm, rhythm: regular, effort: unlabored Spot: Your Findings
- Abdominal pain on/off x 2 years after he eats. goes away after a few minutes
- Abdomen minimal tenderness diffusely on
exam
. Hypoactive bowel sounds
- Watery stool. incontinence x 3 weeks
- Stools are small, hard. like little pebbles
- pain with defecation x 2 years
- Picky eater, no vegetables, chicken nuggets,
pizza, fried foods, treats, milk 4- 5
- Wom drink water
- BM every 4-5 days
- Last BM 5 days ago
- Increased stress - parents getting divorce 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
Feedback
Leaking stool in his underwear for 3 Since this is the most distressing symptom tor 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 1
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 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 "cant 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.
Feedback
ÝouF Différehtial biágnbsès Legend: Correct X Missed encopresis
- hypothyroidism gluten-sensitive enteropathy (celiac disease) X congenital aganglionic megacolon (Hirschsprungts disease) X constipation
Select test to show results
and interpretations.
Author did not select any tests for this case. Diagnosis Feedback Encopresis Eneopresis or soihng is also known as fecal incontinence. 't usually occurs in children four years and older where a child is toilet trained and has bowel control. The child resis's having bowel movements which cause stool to be impacted in the colon and rectum. Liquid stool then leaks around the impacted into the child's underwear AOÞtO*imatelV Of Children With encopresis have undertving constioatiOfi, Constipation Can be associated With several environmental triggers, These are:
- Introduction of cereal and solid foods into the child's diet
- Cornrnancernent of toilet training
- Start Of SthOOl
- Separation/sttess trom parents or schedule changes Severe constipation causes further stooi withholding and worsens constipation. Symptoms Of include: Leakage o' stool in the child's underwear, often mistaken by parents 'or diarrhea
- Avoidance of bowel movements
- Constipation
- pain
- Urinary tract infections Plan Feedback Care:
- Initial cleanout dosing: Give polyethylene glycol (PEG) 335017 g/dose, dose mixed in 6-802 of
water or juice over 3 hours,
- It no response, repeat the same dose tomorrow.
- Maintenance dosing: Give polyethylene glycol (PEG) 3350 17g/dose, 1/2 dose mixed in 6-8 OŽ
Water or juice dai'y,
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.
- Hava the patient sit an 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 Ot 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
- Maintain previously scheduled *year-old well-child visit for routine vaccinations and anticipatory
guidance.
