Constipation in child

Age: ‍ ‍monthsyears old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of constipation

Infrequent bowel movements decreased to ‍ times per week, with the last one occurring ‍ days ago

Stools described as ‍hard, ‍lumpy, ‍dry, ‍small in volume, ‍large in diameter, with ‍straining

Alleviating factors: ‍nonedietary modificationslaxatives, ‍effectiveineffective

Diet: fiber intake ‍adequate, fruits and vegetables ‍adequate, fluid intake ‍adequate



Associated symptoms: *Try using right-click for negatives*

‍abdominal discomfort

‍abdominal pain, ‍diffuse, ‍dull, ‍mild

‍rectal pain or pressure

‍bloating

‍nausea

‍vomiting, ‍ episodes ‍per day, ‍, ‍hematemesis

‍loss of appetite

‍inability to pass gas

‍weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths, ‍unintentionalintentional

‍failure to thrive

‍fever, up to ‍°, over ‍ ‍hoursdays

‍fatigue

‍anal pain

‍rectal bleeding, ‍oncetwice ‍, ‍bright reddark red, ‍withwithout clots

‍dark, tarry stools

‍anxiety



Contributing factors:

‍stress

‍low fiber diet

‍low fluid intake

‍sedentary lifestyle

‍delaying the urge to have a bowel movement

no history of: ‍chronic constipation, ‍hypothyroidism, ‍anal fissures, ‍hemorrhoids

no use of: ‍opioids, ‍antidepressants, ‍iron supplements, ‍new medication





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Metrics: length: ‍ cm - ‍th perc, weight: ‍ kg - ‍th perc, BMI: ‍ - ‍th perc

Ears: tympanic membranes ‍normal ‍, auditory canal ‍ on ‍rightleft, hearing ‍intact

Throat: ‍normal, ‍palate intact, ‍redness

Neck: ‍normal, ‍lymphadenopathy, ‍nuchal rigidity, ‍torticollis, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Anorectal: DRE ‍normal, ‍blood, ‍mass, anus ‍

Genitourinary: external genitalia ‍normal, testes ‍descended, penis ‍normal, Tanner stage ‍

Extremities: ‍normal inspection, ‍joints ‍normal, ‍limited ROM, ‍normal spine, Barlow ‍negative, Ortolani ‍negative, ‍normal pulses, cap refill ‍< 3> 3 sec

Skin: ‍rashlesions on ‍

Neurologic: cranial nerves ‍grossly intact, overall motricity ‍normal for agelimb weakness, muscle tone ‍normal for age, gait ‍appropriate for age, reflexes ‍intact 2+





ASSESSMENT:

‍Constipation ‍likelysuspectedpossible

DDx: functional constipation, dehydration, low fiber intake, cow's milk protein intolerance, Hirschsprung disease, hypothyroidism, celiac disease, intestinal obstruction, anal fissure, neurological disorders, lead poisoning, medication side effect, toilet training issues, psychosocial factors, encopresis





PLAN:

Investigations:

- Blood work: ‍CBC, ‍TSH, ‍electrolytes, ‍calcium, ‍glucose, ‍anti-transglutaminase

- Abdominal ultrasound

- Rectal biopsy if Hirschsprung's disease is suspected

Treatments:

- Increase dietary fiber (fruits, vegetables, whole grains)

- Increase fluid intake

- Regular physical activity

- Scheduled toileting: encourage child to sit on the toilet for 5 minutes after meals, up to 3 times per day, emphasized on making it a positive activity

- Parents advised not to insist on bowel movements

- Star chart to record progress

- ‍Polyethylene glycol

- ‍Laxatives and softeners

- ‍Suppositories

- ‍Enemas

- ‍Lidocaine

Further care:

- Referral to pediatrician

- Referral to dietitian

- Follow-up in ‍ ‍weeksmonths

- Return if constipation worsens, if new symptoms develop such as abdominal pain, fever, or blood in stools