MAX KING LEAKING STOOL iHUMAN CASE STUDY SOLUTION, Exams of Nursing

Download MAX KING LEAKING STOOL iHUMAN CASE STUDY SOLUTION and more Exams Nursing in PDF only on Docsity! Max King 4yo0 3’4 40 Ib CC: leaking stool in his underwear Graded Approach Question How can | help him today? - CLiSx (witness) 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 a day? (witness) Has he had any more stress in X Etiology s life lately? (witness) AN NN AAAMTMN £ 2l _ 1 1M1 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) ies? PMH Do_es he have any allergies? (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. 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. : e a n I i n n c a u ni ip d i a u - Select test to show results and interpretations. Author did not select any tests for this case. Diagnosis Feedback Encopresis Encopresis or soiling is also known as fecal incontinence. It usually occurs in children four years and older where a child is toilet trained and has bowel control. The child resists having bowel movements which cause stool to be impacted in the colon and rectum. Liquid stool then leaks around the impacted stool into the child's underwear. Approximately 80% of children with encopresis have underlying constipation. Constipation can be associated with several environmental triggers. These are: « Introduction of cereal and solid foods into the child's diet « Commencement of toilet training « Start of school « Separation/stress from parents or schedule changes Severe constipation causes further stool withholding and worsens constipation. Symptoms of encopresis include: » Leakage of stool in the child's underwear, often mistaken by parents for diarrhea » Avoidance of bowel movements « Constipation « Abdominal pain o Urinary tract infections 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.