Version 1 and 2
Max kings i- human case study cc; leaking stool
Content; HPI STATEMENT, HISTORY, PHYSICAL EXAM, TESTING, DIFFERENTIAL DIAGNOSIS,
SUMMARY, PLAN FOR PATIENT , EXERCISES, EXPERT FEEDBACK,CASE SUMMARY
,Version 1 and 2
Max kings i- human case study cc; leaking stool
HPI
Max King is a 4-years 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 his child had
intermittent abdominal pain for 2 years and had experienced hard stools as well. He also reported
that his child started having watering stools, 2-3 times in a day for the past 3-weeks. He went
further to explained that the abdominal pain usually starts after eating and gets better a few
minutes.
According to max’s father, he states that his son is picky eater, and do not eat vegetables or
healthy. Max is known to love eating fried food and dessert, drink three cups of milks in a day,
and do not drink enough water.
The father mentioned that max is potty trained, and he denies nausea or vomiting, fever, bleeding
with defecation, and headache. He reported of straining when defecating.
Physical examination revealed a diffuse tenderness to palpation of the abdomen.
Treatment/Management Plan
Primary Diagnosis: Encopresis and ICD-10 code: F98.1
• Encopresis sometimes called stool soiling can been defined as an intentional or
involuntary movement of stools into the underwear or clothing. It usually occurs in toilet
trained children with developmental age that is greater or equals to 4 years. The child
usual resist defecation which causes feces to be impacted in the colon leading to
constipation, and later followed by leaking watery stool (Colombo et al., 2017).
In most cases, it happens because a child has a chronic constipation. Some of the
symptoms include the need to have a bowel movement with little or no warning, lose or
watery stool, leakage of stool into the underwear, intermittent abdominal pain,
constipation, avoiding defecation, and urinary tract infections.
In this case Max has all the symptoms of encopresis, and both the subjective and
objective data supported the diagnosis with the abdominal x-ray that showed impacted
large stools in the colon.
Differential Diagnosis
• Celiac disease – K90.0: This is a genetic autoimmune reaction to eating gluten, a
proteinfound in wheat, barley, and rye, which can affect the gut, and other organs
(Wolters Kluwer Health., 2016). Some of the symptoms includes diarrhea, constipation,
nausea, vomiting, and weight loss. Max had diarrhea, constipation but there is no report
of weightloss, nausea, vomiting, or eating any food that has gluten. The text did to rule
,Version 1 and 2
out, were negative for celiac disease. So, celiac disease is not the primary diagnosis.
• Hypothyroidism- E03.9: This is a condition whereby the thyroid gland do not produce
enough of thyroid hormones. Some of the symptoms are fatigue, constipation, and dry
skin. Though, max has had constipation, but never complain of fatigue or skin dryness,
and thyroid function test where negative. So, we rule out hypothyroidism as the primary.
• Constipation- K59.00: dissatisfying excretion of feces mark by infrequent stools,
difficult stool passage or both. Some of the characteristics include less three bowel
movements a week, hard stools, excessive straining, prolonged time spent on the toilet, a
sense of incomplete evacuation, hard or small stools, difficulty passing feces, and
abdominal discomfort, such as pain, and bloating. This seems to be the diagnosis but
based on the subject and objective information gathered constipation only do not soil
pants and underwear. This should be a supporting diagnosis.
Additional Laboratory and diagnostic tests:
• UA/Urine culture to check for UTI/glucosuria.
• Thyroid function tests: hypothyroidism
• Abdominal x-ray to check for stool impaction: Result showing a large amount of stool
filling the rectum and sigmoid colon.
• Antigliadin antibodies (IgA, IgE, IgG): Use to diagnosed celiac disease.
• Electrolyte panel including calcium to check for hypokalemia, hypercalcemia, or
hyperglycemia.
Consults/Referrals.
• Nutritionist for dietary management.
• Counseling, and behavioral therapy may be considered due to parents’ divorce which may
be a contributing factor.
Therapeutic Modalities
Pharmacological management/treatment:
• Dis-impaction with polyethylene glycol. 1.5g/kg/day, orally, daily for 3 days, and
maintenance dose of 0.8g/kg/day orally, daily, for six months.
Non-Pharmacological management:
• Dietary changes by eating enough vegetables, eating healthier and drinking adequate
water until he sets up his regular bowel movement.
• Continuation of toilet training until the successful maintenance of a regular bowel
movement.
• Eating high fiber diet, fresh fruits, and fluid intake of 2000 to 3000ml/day if not
contraindicated.
• Being physical active
Health Promotion:
• Early childhood is a time the parents should start to set up healthful eating patterns for the
child and family. These patterns should involve the consumption of vegetables, fruits,
while grains, lean means, and dairy products, and then minimize consumption of goods
, Version 1 and 2
and beverages that has sugars, and too much saturated fats.
• Building a positive dietary habit
• Making sure that your child drink plenty of water
• Regular physical activities are highly recommended.
Patient Education:
• Give your child adequate fluid and fiber intake and reduce cow’s milk products.
• Avoid excessive consumption of fried food, and un-healthy diet.
• Avoid punishing child for soiling underwear, because the stool comes out involuntarily.
• Use positive reinforcement for successful toilet sits and medication compliance.
• Encourage physical activities in school or at home.
Anticipatory Guidance:
• Recognized a specific nutrients, diets, or supplemental needs related to your child’s
condition, and appropriately address it.
• Establish a positive, nurturing environment, and healthy patterns of feeding and eating to
promote eating habits that are built on variety, balance, and moderation.
• Encourage your child to take part in regular physical activities to promote defecation,
improve physical and mental health, and is fun for children.
• 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.
Disposition/Follow-Up: Patient should continue treatment for 6 months, return in 4 weeks for
support and to ensure compliance.
References
Bianco, A., Chaker, L., Jonkklaas, J., and Peeters R. P., (2017). Hypothyroidism. Retrieved July
17,2021, 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 July 17,
2021, from https://pedsinreview.aappublications.org/content/36/9/392
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 July 17, 2021,
from www.sciencedaily.com/releases/2016/01/160119142303.htm
Max kings i- human case study cc; leaking stool
Content; HPI STATEMENT, HISTORY, PHYSICAL EXAM, TESTING, DIFFERENTIAL DIAGNOSIS,
SUMMARY, PLAN FOR PATIENT , EXERCISES, EXPERT FEEDBACK,CASE SUMMARY
,Version 1 and 2
Max kings i- human case study cc; leaking stool
HPI
Max King is a 4-years 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 his child had
intermittent abdominal pain for 2 years and had experienced hard stools as well. He also reported
that his child started having watering stools, 2-3 times in a day for the past 3-weeks. He went
further to explained that the abdominal pain usually starts after eating and gets better a few
minutes.
According to max’s father, he states that his son is picky eater, and do not eat vegetables or
healthy. Max is known to love eating fried food and dessert, drink three cups of milks in a day,
and do not drink enough water.
The father mentioned that max is potty trained, and he denies nausea or vomiting, fever, bleeding
with defecation, and headache. He reported of straining when defecating.
Physical examination revealed a diffuse tenderness to palpation of the abdomen.
Treatment/Management Plan
Primary Diagnosis: Encopresis and ICD-10 code: F98.1
• Encopresis sometimes called stool soiling can been defined as an intentional or
involuntary movement of stools into the underwear or clothing. It usually occurs in toilet
trained children with developmental age that is greater or equals to 4 years. The child
usual resist defecation which causes feces to be impacted in the colon leading to
constipation, and later followed by leaking watery stool (Colombo et al., 2017).
In most cases, it happens because a child has a chronic constipation. Some of the
symptoms include the need to have a bowel movement with little or no warning, lose or
watery stool, leakage of stool into the underwear, intermittent abdominal pain,
constipation, avoiding defecation, and urinary tract infections.
In this case Max has all the symptoms of encopresis, and both the subjective and
objective data supported the diagnosis with the abdominal x-ray that showed impacted
large stools in the colon.
Differential Diagnosis
• Celiac disease – K90.0: This is a genetic autoimmune reaction to eating gluten, a
proteinfound in wheat, barley, and rye, which can affect the gut, and other organs
(Wolters Kluwer Health., 2016). Some of the symptoms includes diarrhea, constipation,
nausea, vomiting, and weight loss. Max had diarrhea, constipation but there is no report
of weightloss, nausea, vomiting, or eating any food that has gluten. The text did to rule
,Version 1 and 2
out, were negative for celiac disease. So, celiac disease is not the primary diagnosis.
• Hypothyroidism- E03.9: This is a condition whereby the thyroid gland do not produce
enough of thyroid hormones. Some of the symptoms are fatigue, constipation, and dry
skin. Though, max has had constipation, but never complain of fatigue or skin dryness,
and thyroid function test where negative. So, we rule out hypothyroidism as the primary.
• Constipation- K59.00: dissatisfying excretion of feces mark by infrequent stools,
difficult stool passage or both. Some of the characteristics include less three bowel
movements a week, hard stools, excessive straining, prolonged time spent on the toilet, a
sense of incomplete evacuation, hard or small stools, difficulty passing feces, and
abdominal discomfort, such as pain, and bloating. This seems to be the diagnosis but
based on the subject and objective information gathered constipation only do not soil
pants and underwear. This should be a supporting diagnosis.
Additional Laboratory and diagnostic tests:
• UA/Urine culture to check for UTI/glucosuria.
• Thyroid function tests: hypothyroidism
• Abdominal x-ray to check for stool impaction: Result showing a large amount of stool
filling the rectum and sigmoid colon.
• Antigliadin antibodies (IgA, IgE, IgG): Use to diagnosed celiac disease.
• Electrolyte panel including calcium to check for hypokalemia, hypercalcemia, or
hyperglycemia.
Consults/Referrals.
• Nutritionist for dietary management.
• Counseling, and behavioral therapy may be considered due to parents’ divorce which may
be a contributing factor.
Therapeutic Modalities
Pharmacological management/treatment:
• Dis-impaction with polyethylene glycol. 1.5g/kg/day, orally, daily for 3 days, and
maintenance dose of 0.8g/kg/day orally, daily, for six months.
Non-Pharmacological management:
• Dietary changes by eating enough vegetables, eating healthier and drinking adequate
water until he sets up his regular bowel movement.
• Continuation of toilet training until the successful maintenance of a regular bowel
movement.
• Eating high fiber diet, fresh fruits, and fluid intake of 2000 to 3000ml/day if not
contraindicated.
• Being physical active
Health Promotion:
• Early childhood is a time the parents should start to set up healthful eating patterns for the
child and family. These patterns should involve the consumption of vegetables, fruits,
while grains, lean means, and dairy products, and then minimize consumption of goods
, Version 1 and 2
and beverages that has sugars, and too much saturated fats.
• Building a positive dietary habit
• Making sure that your child drink plenty of water
• Regular physical activities are highly recommended.
Patient Education:
• Give your child adequate fluid and fiber intake and reduce cow’s milk products.
• Avoid excessive consumption of fried food, and un-healthy diet.
• Avoid punishing child for soiling underwear, because the stool comes out involuntarily.
• Use positive reinforcement for successful toilet sits and medication compliance.
• Encourage physical activities in school or at home.
Anticipatory Guidance:
• Recognized a specific nutrients, diets, or supplemental needs related to your child’s
condition, and appropriately address it.
• Establish a positive, nurturing environment, and healthy patterns of feeding and eating to
promote eating habits that are built on variety, balance, and moderation.
• Encourage your child to take part in regular physical activities to promote defecation,
improve physical and mental health, and is fun for children.
• 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.
Disposition/Follow-Up: Patient should continue treatment for 6 months, return in 4 weeks for
support and to ensure compliance.
References
Bianco, A., Chaker, L., Jonkklaas, J., and Peeters R. P., (2017). Hypothyroidism. Retrieved July
17,2021, 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 July 17,
2021, from https://pedsinreview.aappublications.org/content/36/9/392
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 July 17, 2021,
from www.sciencedaily.com/releases/2016/01/160119142303.htm
