GI SOAP note – constipation in pediatric patient

GI SOAP note – constipation in pediatric patient

TOPIC: GI ISSUE IN A PEDIATRIC PATIENT.

THE CHIEF COMPLAINT – NOT POOPING/CONSTIPATION

Complete a Focused SOAP Note Template in which you will gather patient information, relevant diagnostic and treatment information, and reflect on health promotion and disease prevention in light of patient factors, such as age, ethnic group, past medical history (PMH), socio-economic status, cultural background, etc.

• Use the Focused SOAP Note Template

• Subjective: What details did the patient or parent provide regarding the personal and medical history? Include any discrepancies between the details provided by the child and details provided by the parent as well as possible reasons for these discrepancies.
• Objective: What observations did you make during the physical assessment? Include pertinent positive and negative physical exam findings. Describe whether the patient presented with any growth and development or psychosocial issues.
• Assessment: What were your differential diagnoses? Provide a minimum of three possible diagnoses. List them from highest priority to lowest priority and include their ICD-10 codes for the diagnosis. What was your primary diagnosis and why?
• Plan: What was your plan for diagnostics and primary diagnosis? What was your plan for treatment and management? Include pharmacologic and non-pharmacologic treatments, alternative therapies, and follow-up parameters as well as a rationale for this treatment and management plan.
• Reflection notes: What was your “aha” moment? What would you do differently in a similar patient evaluation?

 

GI SOAP note – constipation in pediatric patient

Episodic/Focused SOAP Note Template

 Patient Information:

A.T, 4, Female, African American

S.

CC (chief complaint): “Not pooping for 4 days.”

HPI: A.T. is a 4-year-old African American female who presents with her mother, complaining of constipation. The mother reports that A.T. has not had a bowel movement in four days. Her last bowel movement was small, hard, and painful. The mother notes that A.T. has had intermittent episodes of constipation for about 2 months. The episodes typically resolve with the use of prune juice or increased fiber intake but have recently become more frequent. The mother describes A.T.’s bowel movements as being hard, dry, and causing her to cry due to pain during defecation. There are no associated signs of nausea, vomiting, or fever. A.T. has been drinking less water than usual over the past week, and her diet has included more processed foods and less fresh fruits and vegetables. The patient has also been more sedentary than usual due to a recent cold, resulting in less physical activity. The mother denies any recent changes in medications or other health concerns. The severity of her constipation is noted as 7/10 by the mother based on A.T.’s discomfort.

Current Medications: None

Allergies: No known drug allergies. No known food or environmental allergies

PMHx: No history of significant illnesses. Immunizations are up-to-date, including DTaP, MMR, Polio, Varicella, and Hepatitis A/B. Last flu shot was in September 2023 GI SOAP note – constipation in pediatric patient.

Soc & Substance Hx: A.T. is a preschooler who attends daycare three times a week. Her mother works part-time as an office manager, and her father works from home. There is no exposure to tobacco smoke at home. The family has a pet dog. Mother reports that A.T. drinks juice and water but dislikes plain water, which has limited her fluid intake lately. No alcohol or substance use, as patient is a minor. Family lives in a smoke-free home with functional smoke detectors and regularly uses seat belts. Her mother reports no concerns with the home environment or safety.

ORDER HERE

Fam Hx:

Mother: History of hypothyroidism, well-managed. No gastrointestinal issues.

Father: History of occasional heartburn. No constipation or chronic GI issues.

Siblings: A.T. has one older brother, aged 7, who has no significant health issues.

Grandparents: Paternal grandmother has a history of hypertension. No GI concerns on either side of the family.

Surgical Hx: None

Mental Hx: No known mental health issues. A.T.’s mother denies concerns regarding anxiety or depression.

Violence Hx: No concerns about violence or safety at home or in the community.

Reproductive Hx: Not applicable (patient is a minor).

ROS:

General: No weight loss, fever, or recent illnesses beyond a mild cold last week.

HEENT: Eyes: No visual disturbances. Ears: No ear pain or infections. Throat: No sore throat or difficulty swallowing.

Skin: No rash or unusual skin conditions.

Cardiovascular: No history of chest pain, palpitations, or edema.

Respiratory: No shortness of breath, coughing, or wheezing.

Gastrointestinal: Hard, painful stools, no bowel movement for 4 days. No blood in the stool, no nausea, vomiting, or abdominal pain.

Genitourinary: No burning during urination, no recent changes in urinary habits.

Neurological: No headaches, dizziness, or weakness. No changes in consciousness or behavior.

Musculoskeletal: No joint or muscle pain.

Endocrine: No history of excessive thirst, urination, or heat intolerance.

Psychiatric: No behavioral concerns, anxiety, or depression.

O.

Physical exam:

Vital Signs: BP 90/60, HR 88 bpm, RR 20, Temp 98.6°F, Height 42 inches, Weight 40 lbs, BMI 18.6.

General: A.T. is a well-nourished, well-developed 4-year-old female, alert, and in no acute distress. She is cooperative during the exam.

HEENT: Normocephalic, atraumatic. No nasal congestion, throat erythema, or tonsillar enlargement.

Abdomen: Soft, mildly distended. No masses, organomegaly, or rebound tenderness. Mild discomfort on palpation in the lower abdomen. Bowel sounds are hypoactive.

Skin: Warm, dry, no rashes or bruises.

Cardiovascular: S1 and S2 are heard, regular rate and rhythm. No murmurs, gallops, or rubs. Capillary refill is less than 2 seconds.

Respiratory: Clear to auscultation bilaterally. No wheezes, rales, or rhonchi.

Musculoskeletal: Full range of motion in all extremities, no tenderness or swelling.

Neurological: Alert and oriented. No focal neurological deficits noted.

Diagnostic results: No current diagnostics have been performed. A basic metabolic panel and abdominal x-ray are ordered to assess electrolyte balance and check for fecal impaction or other GI obstructions.

A.

Differential Diagnoses

Primary Diagnosis: Constipation (ICD-10 Code: K59.00)

Constipation in children is characterized by infrequent bowel movements, difficulty in passing stools, or hard stools. In A.B.’s case, her mother reports that she has not had a bowel movement for four days. Constipation can be functional, often related to dietary habits, fluid intake, and behavioral factors such as withholding due to fear of pain during defecation. The absence of significant abdominal pain or rectal bleeding reduces the likelihood of organic causes. The lack of dietary fiber and adequate hydration in A.B.’s intake supports this diagnosis. Evidence suggests that increasing fluid and fiber intake can help alleviate constipation in children (Mulhem et al., 2022). Therefore, recommending a diet rich in fruits, vegetables, and whole grains, along with adequate hydration, is crucial. Additionally, establishing regular bathroom routines and encouraging relaxation during bowel movements can aid in managing constipation. Chronic constipation can significantly affect a child’s quality of life, so early intervention is vital to prevent further complications like fecal impaction or encopresis  (Mulhem et al., 2022).

Encopresis (ICD-10-CM Code: R15.9)

Encopresis is the repeated passing of stool in inappropriate places by a child, often due to chronic constipation (DeLeon et al., 2023). Although A.T. is not currently experiencing stool leakage, prolonged constipation could potentially lead to encopresis if left untreated. Assessment for fecal impaction through an abdominal x-ray will help rule out this condition. Encopresis is often a result of stool withholding, leading to chronic constipation and fecal impaction, which may be a consequence of hard and painful stools over time (DeLeon et al., 2023) GI SOAP note – constipation in pediatric patient.

Hirschsprung’s Disease (ICD-10-CM Code: Q43.1)

Hirschsprung’s disease is a congenital condition that results in the absence of ganglion cells in the intestines, leading to chronic constipation or intestinal obstruction (Lotfollahzadeh et al., 2023). Though A.T.’s symptoms are consistent with functional constipation, Hirschsprung’s disease should be considered in cases of refractory constipation in children.This condition typically presents with severe constipation from infancy, which is not the case here. The absence of fecal incontinence and normal growth and development in A.T. make Hirschsprung’s less likely, but it will be ruled out with imaging and if necessary, a rectal biopsy.

Celiac Disease (ICD-10-CM Code: K90.0)

Celiac disease is an autoimmune disorder where ingestion of gluten leads to damage in the small intestine, resulting in malabsorption and gastrointestinal symptoms, including constipation (Sahin, 2021). Although A.T. has no associated symptoms of malabsorption, like weight loss or diarrhea, chronic constipation could indicate an underlying food intolerance, such as gluten sensitivity. Given that A.T.’s constipation seems primarily related to dietary changes and low fluid intake, this diagnosis is less likely but could be explored further if constipation persists despite initial interventions.

P.

Diagnostic Studies:

Abdominal X-ray: This study will be obtained to assess for fecal impaction or gastrointestinal obstruction due to A.T.’s history of constipation and mild abdominal discomfort.

Basic Metabolic Panel (BMP): This will be performed to evaluate A.T.’s electrolyte balance and kidney function, considering her recent decreased fluid intake.

Referrals:

Pediatric Gastroenterology: Refer to a specialist for evaluation and treatment options for significant fecal impaction or persistent constipation.

Dietitian: Refer for assistance in developing a balanced diet plan that includes adequate fiber and fluid intake tailored to A.T.’s preferences and lifestyle.

Therapeutic Interventions:

Medication: Administer Polyethylene Glycol (PEG) 3350 10g per day. Mix the prescribed dose of PEG 3350 with 4-8 ounces of water or juice. Administer once daily until A.T. has a bowel movement, then reassess and adjust the dosage as needed to maintain regular bowel movements. PEG is an osmotic laxative that helps to draw water into the bowel, softening the stool and promoting bowel movements (Gaballa et al., 2023).

Dietary Modifications: Educate the mother to increase A.T.’s dietary fiber intake through fruits, vegetables, and whole grains. Implement fiber supplements (e.g., psyllium husk) to ensure A.T. consumes at least 14 grams of fiber for every 1,000 calories GI SOAP note – constipation in pediatric patient.

Hydration: Instruct the mother to encourage A.T. to drink more fluids, particularly water. Recommend mixing water with a splash of juice to enhance palatability and improve hydration.

Physical Activity: Advise that A.T. engages in active playtime and outdoor activities to promote gastrointestinal motility.

Education:

Discuss the significance of maintaining regular bowel habits and a fiber-rich diet in preventing constipation. Provide educational materials detailing constipation management and the importance of dietary factors.

Educate the mother on recognizing signs of complications, such as severe abdominal pain, rectal bleeding, or changes in bowel habits, which require immediate medical attention.

Follow-Up:

Schedule a follow-up visit in 2-4 weeks to monitor A.T.’s bowel habits and evaluate the effectiveness of dietary changes. Adjust treatment based on A.T.’s progress.

Reflections:

Upon reviewing this case, I fully support my preceptor’s treatment plan, which focuses on medication management, dietary modifications, and hydration. These are key strategies supported by evidence-based practices for managing childhood constipation. This approach effectively addresses A.T.’s symptoms while preventing complications. From this case, I gained insights into the critical role of diet and lifestyle in managing gastrointestinal health in pediatric patients. The need for parental involvement in the management plan is crucial to ensuring compliance and success GI SOAP note – constipation in pediatric patient.

Moving forward, I will incorporate a comprehensive dietary assessment to better understand a child’s preferences and barriers to healthy eating. Additionally, considering cultural factors and socioeconomic status is essential for implementing effective health promotion and disease prevention strategies. Through tailoring interventions to A.T.’s specific age, background, and family dynamics, I can foster a supportive environment for her health and well-being.

 References

DeLeon, J., Shrestha, M., Mahmood, Z., & Patel, D. R. (2023). Encopresis review. International Journal of Child & Adolescent Health, 16(4).

Gaballa, S., Naguib, Y., Mady, F., & Khaled, K. (2023). Polyethylene glycol: Properties, applications, and challenges. Journal of advanced Biomedical and Pharmaceutical Sciences, 0(0), 26-36. https://doi.org/10.21608/jabps.2023.241685.1205

Lotfollahzadeh, S., Taherian, M., & Anand, S. (2023). Hirschsprung disease. In StatPearls [Internet]. StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK562142/

Mulhem, E., Khondoker, F., & Kandiah, S. (2022). Constipation in children and adolescents: evaluation and treatment. American family physician, 105(5), 469-478. https://www.aafp.org/pubs/afp/issues/2022/0500/p469.html

Sahin, Y. (2021). Celiac disease in children: A review of the literature. World Journal of Clinical Pediatrics, 10(4), 53-71. https://doi.org/10.5409/wjcp.v10.i4.53 GI SOAP note – constipation in pediatric patient