HISTORY:
Constipation for
Frequency: times per week, with the last one days ago
Stools type: , with
Treatments tried: ,
Diet: fiber intake , fruits and vegetables , fluid intake
, episodes , ,
, up to °, over
, , , clots
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Measurements: height: cm - perc, weight: kg - perc, BMI:
Ears: -R: , -L:
Throat:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Anorectal: DRE , anus
Genital: , testicles , penis , Tanner stage
Extremities: , , cap refill
Skin:
Neurologic: cranial nerves , global motricity , muscle tone , gait
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , , , ,
- Abdominal ultrasound
- Rectal biopsy if Hirschsprung's disease is suspected
- 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
-
-
-
-
-
- Referral to pediatrician
- Referral to dietitian
- Follow-up in
- Return if constipation worsens, if new symptoms develop such as abdominal pain, fever, or blood in stools