I Human Week 7 Case Study – 4-year-old Male With Leaking
Stool (encopresis)
Comprehensive Case Study
Pa ent Profile
Age: 4 years
Sex: Male
Se ng: Pediatric primary care clinic
Source of History: Mother (reliable historian)
, Chief Concern (CC)
"My son keeps having stool stains in his underwear even though he is po y trained."
History of Present Illness (HPI)
A 4-year-old male brought to the clinic by his mother due to ongoing stool leakage into his
underwear for the past 4 months. The mother reports that A.B. was fully toilet trained by age 3
but began having frequent stool accidents shortly a er star ng preschool.
The stools are described as so to semi-formed and o en foul-smelling. A.B. does not seem
aware when leakage occurs and denies abdominal pain. The mother reports that he avoids
using the toilet for bowel movements and may withhold stool, o en hiding when he feels the
urge to defecate. Episodes occur several mes per week.
Diet history reveals limited fiber intake and high consump on of processed foods. Fluid intake is
low. No blood in stool, vomi ng, fever, or weight loss is reported. There is no history of
congenital gastrointes nal disorders.
Past Medical History (PMH)
Chronic cons pa on (intermi ent)
No hospitaliza ons or surgeries
Birth and Developmental History
Gesta on: Full-term
Delivery: Uncomplicated vaginal delivery
Developmental milestones: Age appropriate
Toilet training: Achieved at age 3
Stool (encopresis)
Comprehensive Case Study
Pa ent Profile
Age: 4 years
Sex: Male
Se ng: Pediatric primary care clinic
Source of History: Mother (reliable historian)
, Chief Concern (CC)
"My son keeps having stool stains in his underwear even though he is po y trained."
History of Present Illness (HPI)
A 4-year-old male brought to the clinic by his mother due to ongoing stool leakage into his
underwear for the past 4 months. The mother reports that A.B. was fully toilet trained by age 3
but began having frequent stool accidents shortly a er star ng preschool.
The stools are described as so to semi-formed and o en foul-smelling. A.B. does not seem
aware when leakage occurs and denies abdominal pain. The mother reports that he avoids
using the toilet for bowel movements and may withhold stool, o en hiding when he feels the
urge to defecate. Episodes occur several mes per week.
Diet history reveals limited fiber intake and high consump on of processed foods. Fluid intake is
low. No blood in stool, vomi ng, fever, or weight loss is reported. There is no history of
congenital gastrointes nal disorders.
Past Medical History (PMH)
Chronic cons pa on (intermi ent)
No hospitaliza ons or surgeries
Birth and Developmental History
Gesta on: Full-term
Delivery: Uncomplicated vaginal delivery
Developmental milestones: Age appropriate
Toilet training: Achieved at age 3
