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NRNP 6541 WEEK 7 COURTNEY GRAHAM I HUMAN
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NRNP 6541 WEEK 7 COURTNEY GRAHAM IHUMAN
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
• 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
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.
• 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
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