Assignment Prompt & Instructions
The episode was unwitnessed by providers but observed by his mother.
– 2 years ago
**files (3)**
– ## case2todo.docx
– ## ME_Sample_CaseStudy_.docx
– N638CaseStudyGradingRubric_2025.docx
**## case2todo.docx**
**Syncope, Weakness, Anorexia, Brain Tumor15554303'. Case/ake Nine**
**S:** 16-year-old Hispanic male with weakness and reported loss of consciousness on Sunday for approximately 2–3 minutes. The episode was unwitnessed by providers but observed by his mother. He regained awareness quickly and was oriented. No EMS called or ER evaluation performed. Patient has a history of brain tumor with surgeries in 2016 and 2020; receives monthly chemotherapy. Complaints of fatigue, shortness of breath on exertion, poor appetite, difficulty walking, and generalized weakness. Often sleeps during the day and struggles to expectorate sputum. Uses a walker or cane for ambulation.
Mother confirms poor appetite and notes he has not been eating well. Last labs (2/6/25) were WNL. No vomiting or GI symptoms. Neurology consult is scheduled in 2 weeks.
**Past Medical History:** Brain tumor with surgeries (2016, 2020), on chemotherapy
**Social History:** Lives with mother, no current school attendance due to medical condition
**O:** **VS:** Temp: 98.6°F | HR: not taken | RR: not taken | BP: not taken | Wt: 147.6 lbs (66.95 kg) | Ht: 60 in (152.4 cm) | BMI: 28.82 (95.98%)
**General:** Alert, well-nourished, no acute distress
**Head:** Normocephalic, atraumatic.
**Eyes:** PERRLA, sclera anicteric.
**ENT:** Moist mucosa, clear throat.
**Neck:** Supple, full ROM, no LAD.
**Skin:** Warm, dry, no rashes
**Heart:** RRR, no murmurs, normal S1/S2.
**Lungs:** Clear to auscultation, good air movement
**Abdomen:** Soft, nontender, no organomegaly.
**Extremities:** No edema, no cyanosis or clubbing
**Neuro:** Alert, oriented x3, generalized weakness with ambulation, uses walker; no focal deficits
**A:** **R53.1** – Weakness.
**R63.0** – Anorexia.
**Z85.841** – Personal history of brain tumor.
**Z51.11** – Encounter for antineoplastic chemotherapy
**P:** **Weakness**: Safety reinforced, use of walker/cane encouraged, continue neurology referral
**Anorexia**: Counsel on iron-rich and calorie-dense foods: lean meats, fortified cereals, beans, greens. Vitamin B12, folate, and Vitamin C-rich foods recommended. Encourage small, frequent meals and high-calorie shakes. Monitor for weight loss and hydration status. Energy conservation techniques recommended. Moderate exercise with clearance from oncologist
**Education:** Emphasized nutrition, hydration, and rest. Encouraged mother to monitor for any new neurologic symptoms, prolonged fatigue, vomiting, or worsening weakness. Instructed to go to ER for any acute changes in consciousness, severe fatigue, vomiting, seizures, or breathing issues. Regular follow-up with oncology, neurology, and PCP encouraged.
**Follow-Up:** Neurology in 2 weeks. RTC in 3 months or sooner if symptoms worsen
**## ME_Sample_CaseStudy_.docx**
1
2
**CC:**(10 yo female with constipation x 4 days)
**HPI**: D.E. is a 10-year-old black female with no significant PMH who presents to the office for a sick visit, accompanied by his mother for a constipation evaluation. She has had hard stools, straining with bowel movements, and minimal discomfort for the last 4 days. There is no abdominal pain, vomiting, fever, or blood in stool. The patient has no recent dietary change or illness. Normal baseline pattern: The patient’s mother reports that she usually has one bowel movement every 1-2 days, which is typically formed and easy to pass. No prior history of chronic constipation requiring medical intervention. Occasional mild constipation in the past, but symptoms usually resolved within 1–2 days with increased fluid intake—no history of fecal incontinence, soiling, or painful defecation. No history of withholding behaviors (e.g., avoiding bowel movements due to fear of pain). She has no history of chronic constipation. The patient is in 5th grade and participates in the gym twice daily.
**Diet:** She likes rice and pasta and occasionally eats vegetables but does not consistently consume fiber-rich foods. Dairy intake: She consumes moderate amounts of milk and cheese, which may contribute to constipation. Fluid intake: The patient drinks adequate water daily and has no excessive intake of sugary drinks or soda.
**Sleep:** Pt sleeps from 8. P.M. to 6 A.M.
**Behavior:** Social interaction is age-appropriate. Has friends and good peer interactions. Engages in structured physical activities —no concerns from school or parents.
**Past Medical History (PMH):** No significant medical history.
Surgical history: None
Medications: None currently prescribed.
Allergies: NKDA.
Immunization: review and Up to date.
Unremarkable prenatal history
**Family History**: Both parents are healthy with no medical history, have two younger siblings, a five-year-old brother who has asthma and a three-year-old sister with Autistic
**Social History:** She lives with her parents and two siblings in a private apartment. He likes to play with his siblings and friends. She attends swimming classes twice a week. She has no sedentary lifestyle concerns (e.g., excessive screen time). The home is smoke-free and pet-free. His grandmother visits twice a month from Ghana and usually stays for five months at a time.
**Review of Systems (ROS)**
**General:** Healthy-appearing, well-nourished, and alert child.
**Skin**: Denies skin, hair, and nail symptoms.
**HEENT: Head:** No history of head injury.
**Eyes:** denies photophobia, glaucoma, or diplopia in his past medical/social history.
**Ears:** canal clear bilaterally. TM clear bilaterally.
**Nose** Pink nasal mucosa, indicating healthy tissue.
**Throat**: No tooth pain or gum bleeding, and oral mucosa pink.
**Neck:** Supple, No lumps, goiter, pain. No swollen glands.
**Lymph Nodes: No** cervical
**Thorax and Lungs:** symmetric.
**Cardiovascular:** no chest pains and no edema.
**Gastrointestinal: Constipation x 4 days**, straining with bowel movements, and passing hard, pellet-like stools. No diarrhea. Reports abdominal discomfort, intermittent, worse after meals. No nausea, vomiting, blood in stool, or excessive gas. Appetite normal/decreased. No history of food intolerance.
Genitourinary: No dysuria, hematuria, or recent urinary tract infections. No urinary incontinence or enuresis.
**Musculoskeletal:** Full motion range and normal flexion and extension
**Respiratory**: No cough, wheezing, or shortness of breath.
**Physical Exam:**
**VS**: BP: 104/68 mmHg- Temperature: 98.4°F; HR: 82 bpm, RR: 18/min, Spo2: 98% on RA. Growth Percentiles: Weight: 28 kg (50th percentile), Height: 130 cm (50th percentile).
**General:** Healthy-appearing child. Well-nourished and alert. Weighs within the normal range. Mucous membranes are moist and pink. The respiratory pattern is unremarkable, with no grunting or nasal flaring.
**Skin:** Warm, dry, no rashes or pallor. No signs of dehydration (no tenting, no dry mucous membranes).
**Head and face**: The size of the skull is developmentally appropriate and is in proportion to the rest of the body. Facial move symmetrically and midline. There is no evidence of dropping, asymmetry, or disproportionate features.
**Eye:** No conjunctival pallor anicteric sclera.
**Neck**: Palpation reveals no lymphadenopathy, swelling, or tenderness. No nuchal rigidity
**Cardiovascular:** Rhythm is regular. No heart murmur, rubs, or gallops. No peripheral edema.
**Respiration:** exhibits normal structure without evidence of curvature or protrusions. Respiration is regular at a rate of 18 bpm. Lungs are clear bilaterally.
**Abdomen:** Inspection: Mild distension noted. No visible peristalsis.
Auscultation: Positive bowel sounds in all four quadrants.
Palpation:
Soft, mild tenderness in LLQ.
No guarding, rebound tenderness, or rigidity.
No hepatosplenomegaly.
No palpable masses.
Percussion: No tympany or dullness no obstruction.
**Neurology:** Reflexes are present and symmetric. Cranial Nerves: No sign of apparent neurological deficit.
**Age-Appropriate Developmental Exam**
At 10 years old, she demonstrates appropriate developmental milestones:
Language: Speaks fluently and understands complex instructions.
Motor Skills: Coordinates fine motor tasks well (e.g., handwriting, drawing).
Social Skills: She engages appropriately with peers and adults.
**Differential Diagnosis (DD)**
**DD#: 1: Functional Constipation**
This is the most likely diagnosis in this case. Functional constipation “is the presence of two or more of the following for a minimum of one month: straining during defecation, hard stools, the sensation of incomplete evacuation, manual maneuvers to facilitate defecation, less than three bowel movements per week, and absence of loose stools without laxatives” (Bashir, & Khan, 2024). This patient has several of the classic characteristics of functional constipation in the form of hard stools, straining, and mild discomfort without the accompaniment of any ominous signs such as hematochezia, fever, or substantial weight loss. The lack of recent diet changes or illness also validates this diagnosis. Relevant positives are low fiber and straining in bowel movements. Relevant negatives are no abdominal pain, vomiting, fever, or systemic symptoms.
**DD#2. Irritable Bowel Syndrome (IBS)**
Though less probable due to the limited symptom duration and lack of alternate constipation/diarrhea, IBS should be considered in the differential diagnosis (Di Rosa et al., 2023). IBS is the recurrent or chronic abdominal pain accompanied by a change in bowel habits, either diarrhea, constipation, or both. As seen in IBS, this patient does not complain of alternating bowel habits, bloating, or mucus with stool. Also, a lack of a chronic course of symptoms excludes IBS as an actual diagnosis at this point. IBS is a clinical diagnosis requiring recurrent symptoms for ≥2 months. Follow-up overtime for different symptoms will discriminate between functional constipation and IBS to assess if constipation becomes recurrent or alternating with diarrhea. The correct positives are a few abdominal pains and alterations in bowel habits. The correct negatives are the absence of diarrhea, bloating, and mucus per stool.
**DD#3. Intestinal Obstruction**
Intestinal obstruction is a more ominous but less likely differential diagnosis. It usually presents with severe pain, vomiting, distension, and reduced bowel sounds. Even though the patient has slight distension and straining, no evidence of severe pain, vomiting, or reduced bowel sounds, characteristic of obstruction, exists (Griffiths & Glancy, 2023). In addition, the slow development and absence of systemic signs are contraindicative of intestinal obstruction here. This diagnosis would be more likely only if the patient worsens or new warning signs appear. Positives of relevance are mild distension and straining. Negatives of relevance are no vomiting, severe pain, or bowel sounds.
**PLAN OF CARE (P)**
Testing and Diagnostic Studies
– No immediate testing is required based on clinical presentation.
– Consider abdominal X-ray if symptoms persist or worsen despite treatment.
**Pharmacologic Treatment**
– Polyethylene Glycol 3350 (MiraLAX)
-Dosing: 0.7–1.5 g/kg/day (maximum 17 g/day) mixed in water daily.
-Patient-Specific Dose: 17 g once daily at night.
**Non-Pharmacologic Treatment**
– Increase fluid intake to at least 6–8 cups of water daily.
– Encourage a high-fiber diet rich in fruits.
– Promote regular toilet habits by encouraging the child to sit on the toilet for 5–10 minutes after daily meals.
**Patient Education**
– Educated the patient and parent about the importance of maintaining adequate hydration and incorporating more fiber into the diet.
– Emphasized the need for consistent toilet habits to establish a routine.
– Advised monitoring for worsening symptoms such as persistent pain, blood in stool, or weight loss, which would require immediate medical attention.
**Anticipatory Guidance**
– Discussed strategies to prevent future episodes of constipation, including maintaining a balanced diet and staying physically active.
– Reinforced the importance of routine wellness visits for ongoing health maintenance.
**Follow-Up**
– RTC if symptoms persist beyond 10 days
– Schedule routine wellness visits in 6 months.
-If symptoms persist, TSH, celiac panel, or abdominal imaging, and refer to GI for further evaluation
References
Bashir, S. K., & Khan, M. B. (2024). Pediatric Functional Constipation: A New Challenge.
_Advanced Gut & Microbiome Research_,
_2024_(1), 5569563.
Di Rosa, C., Altomare, A., Terrigno, V., Carbone, F., Tack, J., Cicala, M., & Guarino, M. P. L. (2023). Constipation-predominant irritable bowel syndrome (IBS-C): Effects of different nutritional patterns on intestinal dysbiosis and symptoms.
_Nutrients_,
_15_(7), 1647.
Griffiths, S., & Glancy, D. G. (2023). Intestinal obstruction.
_Surgery (Oxford)_,
_41_(1), 47-54.
**N638CaseStudyGradingRubric_2025.docx**
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**N638CaseStudyGradingRubric_2025.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/n638casestudygradingrubric-2025-docx-10246877)
**## case2todo.docx**
**Syncope, Weakness, Anorexia, Brain Tumor15554303'. Case/ake Nine**
**S:** 16-year-old Hispanic male with weakness and reported loss of consciousness on Sunday for approximately 2–3 minutes. The episode was unwitnessed by providers but observed by his mother. He regained awareness quickly and was oriented. No EMS called or ER evaluation performed. Patient has a history of brain tumor with surgeries in 2016 and 2020; receives monthly chemotherapy. Complaints of fatigue, shortness of breath on exertion, poor appetite, difficulty walking, and generalized weakness. Often sleeps during the day and struggles to expectorate sputum. Uses a walker or cane for ambulation.
Mother confirms poor appetite and notes he has not been eating well. Last labs (2/6/25) were WNL. No vomiting or GI symptoms. Neurology consult is scheduled in 2 weeks.
**Past Medical History:** Brain tumor with surgeries (2016, 2020), on chemotherapy
**Social History:** Lives with mother, no current school attendance due to medical condition
**O:** **VS:** Temp: 98.6°F | HR: not taken | RR: not taken | BP: not taken | Wt: 147.6 lbs (66.95 kg) | Ht: 60 in (152.4 cm) | BMI: 28.82 (95.98%)
**General:** Alert, well-nourished, no acute distress
**Head:** Normocephalic, atraumatic.
**Eyes:** PERRLA, sclera anicteric.
**ENT:** Moist mucosa, clear throat.
**Neck:** Supple, full ROM, no LAD.
**Skin:** Warm, dry, no rashes
**Heart:** RRR, no murmurs, normal S1/S2.
**Lungs:** Clear to auscultation, good air movement
**Abdomen:** Soft, nontender, no organomegaly.
**Extremities:** No edema, no cyanosis or clubbing
**Neuro:** Alert, oriented x3, generalized weakness with ambulation, uses walker; no focal deficits
**A:** **R53.1** – Weakness.
**R63.0** – Anorexia.
**Z85.841** – Personal history of brain tumor.
**Z51.11** – Encounter for antineoplastic chemotherapy
**P:** **Weakness**: Safety reinforced, use of walker/cane encouraged, continue neurology referral
**Anorexia**: Counsel on iron-rich and calorie-dense foods: lean meats, fortified cereals, beans, greens. Vitamin B12, folate, and Vitamin C-rich foods recommended. Encourage small, frequent meals and high-calorie shakes. Monitor for weight loss and hydration status. Energy conservation techniques recommended. Moderate exercise with clearance from oncologist
**Education:** Emphasized nutrition, hydration, and rest. Encouraged mother to monitor for any new neurologic symptoms, prolonged fatigue, vomiting, or worsening weakness. Instructed to go to ER for any acute changes in consciousness, severe fatigue, vomiting, seizures, or breathing issues. Regular follow-up with oncology, neurology, and PCP encouraged.
**Follow-Up:** Neurology in 2 weeks. RTC in 3 months or sooner if symptoms worsen
**## ME_Sample_CaseStudy_.docx**
1
2
**CC:**(10 yo female with constipation x 4 days)
**HPI**: D.E. is a 10-year-old black female with no significant PMH who presents to the office for a sick visit, accompanied by his mother for a constipation evaluation. She has had hard stools, straining with bowel movements, and minimal discomfort for the last 4 days. There is no abdominal pain, vomiting, fever, or blood in stool. The patient has no recent dietary change or illness. Normal baseline pattern: The patient’s mother reports that she usually has one bowel movement every 1-2 days, which is typically formed and easy to pass. No prior history of chronic constipation requiring medical intervention. Occasional mild constipation in the past, but symptoms usually resolved within 1–2 days with increased fluid intake—no history of fecal incontinence, soiling, or painful defecation. No history of withholding behaviors (e.g., avoiding bowel movements due to fear of pain). She has no history of chronic constipation. The patient is in 5th grade and participates in the gym twice daily.
**Diet:** She likes rice and pasta and occasionally eats vegetables but does not consistently consume fiber-rich foods. Dairy intake: She consumes moderate amounts of milk and cheese, which may contribute to constipation. Fluid intake: The patient drinks adequate water daily and has no excessive intake of sugary drinks or soda.
**Sleep:** Pt sleeps from 8. P.M. to 6 A.M.
**Behavior:** Social interaction is age-appropriate. Has friends and good peer interactions. Engages in structured physical activities —no concerns from school or parents.
**Past Medical History (PMH):** No significant medical history.
Surgical history: None
Medications: None currently prescribed.
Allergies: NKDA.
Immunization: review and Up to date.
Unremarkable prenatal history
**Family History**: Both parents are healthy with no medical history, have two younger siblings, a five-year-old brother who has asthma and a three-year-old sister with Autistic
**Social History:** She lives with her parents and two siblings in a private apartment. He likes to play with his siblings and friends. She attends swimming classes twice a week. She has no sedentary lifestyle concerns (e.g., excessive screen time). The home is smoke-free and pet-free. His grandmother visits twice a month from Ghana and usually stays for five months at a time.
**Review of Systems (ROS)**
**General:** Healthy-appearing, well-nourished, and alert child.
**Skin**: Denies skin, hair, and nail symptoms.
**HEENT: Head:** No history of head injury.
**Eyes:** denies photophobia, glaucoma, or diplopia in his past medical/social history.
**Ears:** canal clear bilaterally. TM clear bilaterally.
**Nose** Pink nasal mucosa, indicating healthy tissue.
**Throat**: No tooth pain or gum bleeding, and oral mucosa pink.
**Neck:** Supple, No lumps, goiter, pain. No swollen glands.
**Lymph Nodes: No** cervical
**Thorax and Lungs:** symmetric.
**Cardiovascular:** no chest pains and no edema.
**Gastrointestinal: Constipation x 4 days**, straining with bowel movements, and passing hard, pellet-like stools. No diarrhea. Reports abdominal discomfort, intermittent, worse after meals. No nausea, vomiting, blood in stool, or excessive gas. Appetite normal/decreased. No history of food intolerance.
Genitourinary: No dysuria, hematuria, or recent urinary tract infections. No urinary incontinence or enuresis.
**Musculoskeletal:** Full motion range and normal flexion and extension
**Respiratory**: No cough, wheezing, or shortness of breath.
**Physical Exam:**
**VS**: BP: 104/68 mmHg- Temperature: 98.4°F; HR: 82 bpm, RR: 18/min, Spo2: 98% on RA. Growth Percentiles: Weight: 28 kg (50th percentile), Height: 130 cm (50th percentile).
**General:** Healthy-appearing child. Well-nourished and alert. Weighs within the normal range. Mucous membranes are moist and pink. The respiratory pattern is unremarkable, with no grunting or nasal flaring.
**Skin:** Warm, dry, no rashes or pallor. No signs of dehydration (no tenting, no dry mucous membranes).
**Head and face**: The size of the skull is developmentally appropriate and is in proportion to the rest of the body. Facial move symmetrically and midline. There is no evidence of dropping, asymmetry, or disproportionate features.
**Eye:** No conjunctival pallor anicteric sclera.
**Neck**: Palpation reveals no lymphadenopathy, swelling, or tenderness. No nuchal rigidity
**Cardiovascular:** Rhythm is regular. No heart murmur, rubs, or gallops. No peripheral edema.
**Respiration:** exhibits normal structure without evidence of curvature or protrusions. Respiration is regular at a rate of 18 bpm. Lungs are clear bilaterally.
**Abdomen:** Inspection: Mild distension noted. No visible peristalsis.
Auscultation: Positive bowel sounds in all four quadrants.
Palpation:
Soft, mild tenderness in LLQ.
No guarding, rebound tenderness, or rigidity.
No hepatosplenomegaly.
No palpable masses.
Percussion: No tympany or dullness no obstruction.
**Neurology:** Reflexes are present and symmetric. Cranial Nerves: No sign of apparent neurological deficit.
**Age-Appropriate Developmental Exam**
At 10 years old, she demonstrates appropriate developmental milestones:
Language: Speaks fluently and understands complex instructions.
Motor Skills: Coordinates fine motor tasks well (e.g., handwriting, drawing).
Social Skills: She engages appropriately with peers and adults.
**Differential Diagnosis (DD)**
**DD#: 1: Functional Constipation**
This is the most likely diagnosis in this case. Functional constipation “is the presence of two or more of the following for a minimum of one month: straining during defecation, hard stools, the sensation of incomplete evacuation, manual maneuvers to facilitate defecation, less than three bowel movements per week, and absence of loose stools without laxatives” (Bashir, & Khan, 2024). This patient has several of the classic characteristics of functional constipation in the form of hard stools, straining, and mild discomfort without the accompaniment of any ominous signs such as hematochezia, fever, or substantial weight loss. The lack of recent diet changes or illness also validates this diagnosis. Relevant positives are low fiber and straining in bowel movements. Relevant negatives are no abdominal pain, vomiting, fever, or systemic symptoms.
**DD#2. Irritable Bowel Syndrome (IBS)**
Though less probable due to the limited symptom duration and lack of alternate constipation/diarrhea, IBS should be considered in the differential diagnosis (Di Rosa et al., 2023). IBS is the recurrent or chronic abdominal pain accompanied by a change in bowel habits, either diarrhea, constipation, or both. As seen in IBS, this patient does not complain of alternating bowel habits, bloating, or mucus with stool. Also, a lack of a chronic course of symptoms excludes IBS as an actual diagnosis at this point. IBS is a clinical diagnosis requiring recurrent symptoms for ≥2 months. Follow-up overtime for different symptoms will discriminate between functional constipation and IBS to assess if constipation becomes recurrent or alternating with diarrhea. The correct positives are a few abdominal pains and alterations in bowel habits. The correct negatives are the absence of diarrhea, bloating, and mucus per stool.
**DD#3. Intestinal Obstruction**
Intestinal obstruction is a more ominous but less likely differential diagnosis. It usually presents with severe pain, vomiting, distension, and reduced bowel sounds. Even though the patient has slight distension and straining, no evidence of severe pain, vomiting, or reduced bowel sounds, characteristic of obstruction, exists (Griffiths & Glancy, 2023). In addition, the slow development and absence of systemic signs are contraindicative of intestinal obstruction here. This diagnosis would be more likely only if the patient worsens or new warning signs appear. Positives of relevance are mild distension and straining. Negatives of relevance are no vomiting, severe pain, or bowel sounds.
**PLAN OF CARE (P)**
Testing and Diagnostic Studies
– No immediate testing is required based on clinical presentation.
– Consider abdominal X-ray if symptoms persist or worsen despite treatment.
**Pharmacologic Treatment**
– Polyethylene Glycol 3350 (MiraLAX)
-Dosing: 0.7–1.5 g/kg/day (maximum 17 g/day) mixed in water daily.
-Patient-Specific Dose: 17 g once daily at night.
**Non-Pharmacologic Treatment**
– Increase fluid intake to at least 6–8 cups of water daily.
– Encourage a high-fiber diet rich in fruits.
– Promote regular toilet habits by encouraging the child to sit on the toilet for 5–10 minutes after daily meals.
**Patient Education**
– Educated the patient and parent about the importance of maintaining adequate hydration and incorporating more fiber into the diet.
– Emphasized the need for consistent toilet habits to establish a routine.
– Advised monitoring for worsening symptoms such as persistent pain, blood in stool, or weight loss, which would require immediate medical attention.
**Anticipatory Guidance**
– Discussed strategies to prevent future episodes of constipation, including maintaining a balanced diet and staying physically active.
– Reinforced the importance of routine wellness visits for ongoing health maintenance.
**Follow-Up**
– RTC if symptoms persist beyond 10 days
– Schedule routine wellness visits in 6 months.
-If symptoms persist, TSH, celiac panel, or abdominal imaging, and refer to GI for further evaluation
References
Bashir, S. K., & Khan, M. B. (2024). Pediatric Functional Constipation: A New Challenge.
_Advanced Gut & Microbiome Research_,
_2024_(1), 5569563.
Di Rosa, C., Altomare, A., Terrigno, V., Carbone, F., Tack, J., Cicala, M., & Guarino, M. P. L. (2023). Constipation-predominant irritable bowel syndrome (IBS-C): Effects of different nutritional patterns on intestinal dysbiosis and symptoms.
_Nutrients_,
_15_(7), 1647.
Griffiths, S., & Glancy, D. G. (2023). Intestinal obstruction.
_Surgery (Oxford)_,
_41_(1), 47-54.
**N638CaseStudyGradingRubric_2025.docx**
This file is too large to display. [View in new window](https://www.sweetstudy.com/files/n638casestudygradingrubric-2025-docx-10246877)
**## case2todo.docx**
**Syncope, Weakness, Anorexia, Brain Tumor15554303'. Case/ake Nine**
**S:** 16-year-old Hispanic male with weakness and reported loss of consciousness on Sunday for approximately 2–3 minutes. The episode was unwitnessed by providers but observed by his mother. He regained awareness quickly and was oriented. No EMS called or ER evaluation performed. Patient has a history of brain tumor with surgeries in 2016 and 2020; receives monthly chemotherapy. Complaints of fatigue, shortness of breath on exertion, poor appetite, difficulty walking, and generalized weakness. Often sleeps during the day and struggles to expectorate sputum. Uses a walker or cane for ambulation.
Mother confirms poor appetite and notes he has not been eating well. Last labs (2/6/25) were WNL. No vomiting or GI symptoms. Neurology consult is scheduled in 2 weeks.
**Past Medical History:** Brain tumor with surgeries (2016, 2020), on chemotherapy
**Social History:** Lives with mother, no current school attendance due to medical condition
**O:** **VS:** Temp: 98.6°F | HR: not taken | RR: not taken | BP: not taken | Wt: 147.6 lbs (66.95 kg) | Ht: 60 in (152.4 cm) | BMI: 28.82 (95.98%)
**General:** Alert, well-nourished, no acute distress
**Head:** Normocephalic, atraumatic.
**Eyes:** PERRLA, sclera anicteric.
**ENT:** Moist mucosa, clear throat.
**Neck:** Supple, full ROM, no LAD.
**Skin:** Warm, dry, no rashes
**Heart:** RRR, no murmurs, normal S1/S2.
**Lungs:** Clear to auscultation, good air movement
**Abdomen:** Soft, nontender, no organomegaly.
**Extremities:** No edema, no cyanosis or clubbing
**Neuro:** Alert, oriented x3, generalized weakness with ambulation, uses walker; no focal deficits
**A:** **R53.1** – Weakness.
**R63.0** – Anorexia.
**Z85.841** – Personal history of brain tumor.
**Z51.11** – Encounter for antineoplastic chemotherapy
**P:** **Weakness**: Safety reinforced, use of walker/cane encouraged, continue neurology referral
**Anorexia**: Counsel on iron-rich and calorie-dense foods: lean meats, fortified cereals, beans, greens. Vitamin B12, folate, and Vitamin C-rich foods recommended. Encourage small, frequent meals and high-calorie shakes. Monitor for weight loss and hydration status. Energy conservation techniques recommended. Moderate exercise with clearance from oncologist
**Education:** Emphasized nutrition, hydration, and rest. Encouraged mother to monitor for any new neurologic symptoms, prolonged fatigue, vomiting, or worsening weakness. Instructed to go to ER for any acute changes in consciousness, severe fatigue, vomiting, seizures, or breathing issues. Regular follow-up with oncology, neurology, and PCP encouraged.
**Follow-Up:** Neurology in 2 weeks. RTC in 3 months or sooner if symptoms worsen
**## ME_Sample_CaseStudy_.docx**
1
2
**CC:**(10 yo female with constipation x 4 days)
**HPI**: D.E. is a 10-year-old black female with no significant PMH who presents to the office for a sick visit, accompanied by his mother for a constipation evaluation. She has had hard stools, straining with bowel movements, and minimal discomfort for the last 4 days. There is no abdominal pain, vomiting, fever, or blood in stool. The patient has no recent dietary change or illness. Normal baseline pattern: The patient’s mother reports that she usually has one bowel movement every 1-2 days, which is typically formed and easy to pass. No prior history of chronic constipation requiring medical intervention. Occasional mild constipation in the past, but symptoms usually resolved within 1–2 days with increased fluid intake—no history of fecal incontinence, soiling, or painful defecation. No history of withholding behaviors (e.g., avoiding bowel movements due to fear of pain). She has no history of chronic constipation. The patient is in 5th grade and participates in the gym twice daily.
**Diet:** She likes rice and pasta and occasionally eats vegetables but does not consistently consume fiber-rich foods. Dairy intake: She consumes moderate amounts of milk and cheese, which may contribute to constipation. Fluid intake: The patient drinks adequate water daily and has no excessive intake of sugary drinks or soda.
**Sleep:** Pt sleeps from 8. P.M. to 6 A.M.
**Behavior:** Social interaction is age-appropriate. Has friends and good peer interactions. Engages in structured physical activities —no concerns from school or parents.
**Past Medical History (PMH):** No significant medical history.
Surgical history: None
Medications: None currently prescribed.
Allergies: NKDA.
Immunization: review and Up to date.
Unremarkable prenatal history
**Family History**: Both parents are healthy with no medical history, have two younger siblings, a five-year-old brother who has asthma and a three-year-old sister with Autistic
**Social History:** She lives with her parents and two siblings in a private apartment. He likes to play with his siblings and friends. She attends swimming classes twice a week. She has no sedentary lifestyle concerns (e.g., excessive screen time). The home is smoke-free and pet-free. His grandmother visits twice a month from Ghana and usually stays for five months at a time.
**Review of Systems (ROS)**
**General:** Healthy-appearing, well-nourished, and alert child.
**Skin**: Denies skin, hair, and nail symptoms.
**HEENT: Head:** No history of head injury.
**Eyes:** denies photophobia, glaucoma, or diplopia in his past medical/social history.
**Ears:** canal clear bilaterally. TM clear bilaterally.
**Nose** Pink nasal mucosa, indicating healthy tissue.
**Throat**: No tooth pain or gum bleeding, and oral mucosa pink.
**Neck:** Supple, No lumps, goiter, pain. No swollen glands.
**Lymph Nodes: No** cervical
**Thorax and Lungs:** symmetric.
**Cardiovascular:** no chest pains and no edema.
**Gastrointestinal: Constipation x 4 days**, straining with bowel movements, and passing hard, pellet-like stools. No diarrhea. Reports abdominal discomfort, intermittent, worse after meals. No nausea, vomiting, blood in stool, or excessive gas. Appetite normal/decreased. No history of food intolerance.
Genitourinary: No dysuria, hematuria, or recent urinary tract infections. No urinary incontinence or enuresis.
**Musculoskeletal:** Full motion range and normal flexion and extension
**Respiratory**: No cough, wheezing, or shortness of breath.
**Physical Exam:**
**VS**: BP: 104/68 mmHg- Temperature: 98.4°F; HR: 82 bpm, RR: 18/min, Spo2: 98% on RA. Growth Percentiles: Weight: 28 kg (50th percentile), Height: 130 cm (50th percentile).
**General:** Healthy-appearing child. Well-nourished and alert. Weighs within the normal range. Mucous membranes are moist and pink. The respiratory pattern is unremarkable, with no grunting or nasal flaring.
**Skin:** Warm, dry, no rashes or pallor. No signs of dehydration (no tenting, no dry mucous membranes).
**Head and face**: The size of the skull is developmentally appropriate and is in proportion to the rest of the body. Facial move symmetrically and midline. There is no evidence of dropping, asymmetry, or disproportionate features.
**Eye:** No conjunctival pallor anicteric sclera.
**Neck**: Palpation reveals no lymphadenopathy, swelling, or tenderness. No nuchal rigidity
**Cardiovascular:** Rhythm is regular. No heart murmur, rubs, or gallops. No peripheral edema.
**Respiration:** exhibits normal structure without evidence of curvature or protrusions. Respiration is regular at a rate of 18 bpm. Lungs are clear bilaterally.
**Abdomen:** Inspection: Mild distension noted. No visible peristalsis.
Auscultation: Positive bowel sounds in all four quadrants.
Palpation:
Soft, mild tenderness in LLQ.
No guarding, rebound tenderness, or rigidity.
No hepatosplenomegaly.
No palpable masses.
Percussion: No tympany or dullness no obstruction.
**Neurology:** Reflexes are present and symmetric. Cranial Nerves: No sign of apparent neurological deficit.
**Age-Appropriate Developmental Exam**
At 10 years old, she demonstrates appropriate developmental milestones:
Language: Speaks fluently and understands complex instructions.
Motor Skills: Coordinates fine motor tasks well (e.g., handwriting, drawing).
Social Skills: She engages appropriately with peers and adults.
**Differential Diagnosis (DD)**
**DD#: 1: Functional Constipation**
This is the most likely diagnosis in this case. Functional constipation “is the presence of two or more of the following for a minimum of one month: straining during defecation, hard stools, the sensation of incomplete evacuation, manual maneuvers to facilitate defecation, less than three bowel movements per week, and absence of loose stools without laxatives” (Bashir, & Khan, 2024). This patient has several of the classic characteristics of functional constipation in the form of hard stools, straining, and mild discomfort without the accompaniment of any ominous signs such as hematochezia, fever, or substantial weight loss. The lack of recent diet changes or illness also validates this diagnosis. Relevant positives are low fiber and straining in bowel movements. Relevant negatives are no abdominal pain, vomiting, fever, or systemic symptoms.
**DD#2. Irritable Bowel Syndrome (IBS)**
Though less probable due to the limited symptom duration and lack of alternate constipation/diarrhea, IBS should be considered in the differential diagnosis (Di Rosa et al., 2023). IBS is the recurrent or chronic abdominal pain accompanied by a change in bowel habits, either diarrhea, constipation, or both. As seen in IBS, this patient does not complain of alternating bowel habits, bloating, or mucus with stool. Also, a lack of a chronic course of symptoms excludes IBS as an actual diagnosis at this point. IBS is a clinical diagnosis requiring recurrent symptoms for ≥2 months. Follow-up overtime for different symptoms will discriminate between functional constipation and IBS to assess if constipation becomes recurrent or alternating with diarrhea. The correct positives are a few abdominal pains and alterations in bowel habits. The correct negatives are the absence of diarrhea, bloating, and mucus per stool.
**DD#3. Intestinal Obstruction**
Intestinal obstruction is a more ominous but less likely differential diagnosis. It usually presents with severe pain, vomiting, distension, and reduced bowel sounds. Even though the patient has slight distension and straining, no evidence of severe pain, vomiting, or reduced bowel sounds, characteristic of obstruction, exists (Griffiths & Glancy, 2023). In addition, the slow development and absence of systemic signs are contraindicative of intestinal obstruction here. This diagnosis would be more likely only if the patient worsens or new warning signs appear. Positives of relevance are mild distension and straining. Negatives of relevance are no vomiting, severe pain, or bowel sounds.
**PLAN OF CARE (P)**
Testing and Diagnostic Studies
– No immediate testing is required based on clinical presentation.
– Consider abdominal X-ray if symptoms persist or worsen despite treatment.
**Pharmacologic Treatment**
– Polyethylene Glycol 3350 (MiraLAX)
-Dosing: 0.7–1.5 g/kg/day (maximum 17 g/day) mixed in water daily.
-Patient-Specific Dose: 17 g once daily at night.
**Non-Pharmacologic Treatment**
– Increase fluid intake to at least 6–8 cups of water daily.
– Encourage a high-fiber diet rich in fruits.
– Promote regular toilet habits by encouraging the child to sit on the toilet for 5–10 minutes after daily meals.
**Patient Education**
– Educated the patient and parent about the importance of maintaining adequate hydration and incorporating more fiber into the diet.
– Emphasized the need for consistent toilet habits to establish a routine.
– Advised monitoring for worsening symptoms such as persistent pain, blood in stool, or weight loss, which would require immediate medical attention.
**Anticipatory Guidance**
– Discussed strategies to prevent future episodes of constipation, including maintaining a balanced diet and staying physically active.
– Reinforced the importance of routine wellness visits for ongoing health maintenance.
**Follow-Up**
– RTC if symptoms persist beyond 10 days
– Schedule routine wellness visits in 6 months.
-If symptoms persist, TSH, celiac panel, or abdominal imaging, and refer to GI for further evaluation
References
Bashir, S. K., & Khan, M. B. (2024). Pediatric Functional Constipation: A New Challenge.
_Advanced Gut & Microbiome Research_,
_2024_(1), 5569563.
Di Rosa, C., Altomare, A., Terrigno, V., Carbone, F., Tack, J., Cicala, M., & Guarino, M. P. L. (2023). Constipation-predominant irritable bowel syndrome (IBS-C): Effects of different nutritional patterns on intestinal dysbiosis and symptoms.
_Nutrients_,
_15_(7), 1647.
Griffiths, S., & Glancy, D. G. (2023). Intestinal obstruction.
_Surgery (Oxford)_,
_41_(1), 47-54.
**N638CaseStudyGradingRubric_2025.docx**
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