What is the rationale for this case? what is the rationale for the secondary diagnosis codes? HPI: 4 Yrs 4 Mos male with pmh sig for chronic constipation who presents with 10 days of abdominal pain. Seen by PMD and diagnosed with viral etiology. Abdominal pain continued to come and go and was seen at Westside Hospital ED and given zofran, miralax-8 grams only given once. and discharged home. Seen 1 day PTA in ED at Mary Children’s Hospital and xray done showing copious stool, and enema give. Evacuation in ED and home feeling better. Once home continued to have abdominal pain and vomited started 1 day prior (NB/NB) and decreased PO intake today. Decreased urination. Abdominal pain continues to be intermittent, and then he will suddenly begin to cry. During episodes, twisting arching of back. No radiation. Stared soy milk 4 days ago as dad thought this was due to milk allergies. No fever. No vomiting today. No recent URI, no easy bruising. Pain when present is periumblical. Mom with history of chronic constipation starting around age 2 1/2. In past 2 weeks, mom has given miralax only once (last night) 8 grams. Past Medical History: No past medical history on file. Past Surgical History: No past surgical history on file. Immunizations: Immunizations Up to Date: Yes Allergies: No Known Allergies Medications: The patient's current medications are listed in the medication portion of the chart. Family History: Cardiac/Sudden Death: negative Diabetes: negative Asthma: negative Hematologic: negative Genetic: negative Social History: Daycare or School:yes Smokers:no Review of Systems: Constitutional: negative Eyes: negative ENT/Mouth: negative CV: negative Respiratory: negative GI: HPI GU/Gyne: negative Last menstrual period: not applicable Musculoskeletal: negative Skin/Breast: negative Neurologic: negative Psychiatric/Developmental: negative Endocrine: negative Hematologic: negative Examination BP: 102/58 Pulse: 108 Temp: 37 °C (98.6 °F) Resp: 28 Weight: 16.6 kg General Appearance: Calm and cooperative in NAD, asking for taco bell Pain: No Head: NCAT Eyes: EOMI PERLA Ears: Tm clear bilaterally Nose: Normal Throat: Normal Mouth/Teeth: mildly erythematous Neck: shotty cervical LN bilaterally Lungs/Chest: Clear to Ausculation, no distress Cardiac: Regular rate and rhythm, no murmur Abdomen:soft, no guarding, no rigidity, no RLQ tenderness, negative rovsing, negative psoas. NO rebound Genitalia/GU: deferred Rectal: small hard stool in vault, heme negative, normal rectal wink Extremities: cap refill < 2 sec Skin: Normal Neurologic: Grossly Normal ED COURSE Alert, active in room. Ate turkey sandwich, apple juice. Abdomen soft, NT ND NABS. Asked dad to take child to bathroom 20 minutes after eating. AXRFINDINGS: No dilated bowel loops or pathologic air-fluid levels are seen to suggest mechanical small bowel obstruction. Large amount of stool is noted throughout the colon, especially the rectum. No free intraperitoneal air. No intraperitoneal calcifications. Osseous structures are unremarkable. Visualized lung bases are clear. IMPRESSION: Large stool burden, mostly in the rectum. Nonobstructive bowel gas. Dad tried to take child to restroom, refused to sit on toliet, crossing legs. Pediatric fleets ordered as stool burden Abdomen soft, NT ND NABS. No guarding no rigidity. Asking for diaper. Large hard stool evacuation after fleets enema in diaper. Per dad, parents are still attempting to potty train but child prefers to stool in diaper. I reassured that this is not uncommon to have struggles with potty training resulting in constipation. Assessment & Plan: 4 Yrs 4 Mos male with history of chronic constipation on miralax with intermittent abdominal pain increasing in frequency in past 2 weeks. Very well appearing with soft, reassuring abdomen. Will observe and repeat xray-with reassuring abdominal exam appendicitis/mass less likely. Abdomen benign throughout observation period and large stool after void within diaper. -start miralax at 17 g (currently not taking prescribed 8 g dose) -hold off on potty training until stooling normal, then restart with lots of praise/incentives/potty time after meals -high fiber diet handout given -strict return criteria discussed
Rationale:
Less intake of fiber in diet making hard stools resulting in fear of bowel elimination with the child resulting in constipation
Anxiety related to training for bowel elimination also resulting in constipation, when the child wore diaper, he passes the stool.
What is the rationale for this case? what is the rationale for the secondary diagnosis codes? HPI...
What is the rationale for this case? what is the rationale for the secondary diagnosis codes? HPI: 4 Yrs 4 Mos male with pmh sig for chronic constipation who presents with 10 days of abdominal pain. Seen by PMD and diagnosed with viral etiology. Abdominal pain continued to come and go and was seen at Westside Hospital ED and given zofran, miralax-8 grams only given once. and discharged home. Seen 1 day PTA in ED at Mary Children’s Hospital and...
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