Structured i-Human Case Study: Esteban Soto – 4-
Year-Old Male With Leaking Stool in Underwear i-
Human format with SOAP note placed after the
references.
I. Chief Complaint
“Stool leaking in underwear.”
II. History of Present Illness (HPI)
Esteban Soto is a 4-year-old male brought in by his mother for recurrent stool leakage in
his underwear for the past few weeks. Leakage is described as small amounts of soft stool
smearing occurring daily, often without the child noticing. Mother reports Esteban has
infrequent bowel movements, sometimes going 3–5 days without a proper stool. When he
does have a bowel movement, the stools are large, hard, and painful. She notes he often
withholds stool, crossing his legs or hiding when he feels the urge.
No vomiting, fever, weight loss, or blood in stool. Appetite normal. Diet low in fiber and
Dominated by rice, pasta, and milk. Toilet trained at age 3. No recent illnesses, travel, or
medication use.
III. Past Medical History
• Full-term birth, no complications
• No chronic conditions
• No prior abdominal issues
• Vaccinations up to date
IV. Medications
• None
V. Allergies
• No known drug, food, or environmental allergies
VI. Family History
• Mother: Anxiety
• Father: Healthy
• No family history of GI disorders, Hirschsprung disease, thyroid disease, or cystic
fibrosis
VII. Social History
, • Lives with parents and older sibling
• Attends preschool
• Typical diet: low fiber, minimal vegetables, high milk intake
• No smoke exposure
VIII. Review of Systems
General: No fever, no weight loss
GI: Constipation, stool withholding, painful defecation, stool leakage, decreased stool
frequency
GU: No urinary incontinence, no dysuria
Skin: No rashes
Neuro: No weakness, normal gait
IX. Physical Examination
General: Alert, cooperative, not in distress
Vitals: WNL for age
Abdomen:
• Mild distension
• Palpable stool mass in LLQ
• No tenderness, guarding, or rebound
Rectal Exam:
• Anal sphincter tone normal
• Vault full of hard stool
• No fissures, no blood
Skin: Clean except for mild perianal irritation from leakage
X. Differential Diagnoses
1. Functional Constipation with Encopresis (Most likely)
o Painful large stools
o Withholding behavior
o Overflow incontinence
o Palpable stool mass
2. Hirschsprung Disease
o Less likely given normal infancy stools and normal growth
3. Anal fissure
o Could contribute to withholding but no fissure seen
4. Celiac Disease
Year-Old Male With Leaking Stool in Underwear i-
Human format with SOAP note placed after the
references.
I. Chief Complaint
“Stool leaking in underwear.”
II. History of Present Illness (HPI)
Esteban Soto is a 4-year-old male brought in by his mother for recurrent stool leakage in
his underwear for the past few weeks. Leakage is described as small amounts of soft stool
smearing occurring daily, often without the child noticing. Mother reports Esteban has
infrequent bowel movements, sometimes going 3–5 days without a proper stool. When he
does have a bowel movement, the stools are large, hard, and painful. She notes he often
withholds stool, crossing his legs or hiding when he feels the urge.
No vomiting, fever, weight loss, or blood in stool. Appetite normal. Diet low in fiber and
Dominated by rice, pasta, and milk. Toilet trained at age 3. No recent illnesses, travel, or
medication use.
III. Past Medical History
• Full-term birth, no complications
• No chronic conditions
• No prior abdominal issues
• Vaccinations up to date
IV. Medications
• None
V. Allergies
• No known drug, food, or environmental allergies
VI. Family History
• Mother: Anxiety
• Father: Healthy
• No family history of GI disorders, Hirschsprung disease, thyroid disease, or cystic
fibrosis
VII. Social History
, • Lives with parents and older sibling
• Attends preschool
• Typical diet: low fiber, minimal vegetables, high milk intake
• No smoke exposure
VIII. Review of Systems
General: No fever, no weight loss
GI: Constipation, stool withholding, painful defecation, stool leakage, decreased stool
frequency
GU: No urinary incontinence, no dysuria
Skin: No rashes
Neuro: No weakness, normal gait
IX. Physical Examination
General: Alert, cooperative, not in distress
Vitals: WNL for age
Abdomen:
• Mild distension
• Palpable stool mass in LLQ
• No tenderness, guarding, or rebound
Rectal Exam:
• Anal sphincter tone normal
• Vault full of hard stool
• No fissures, no blood
Skin: Clean except for mild perianal irritation from leakage
X. Differential Diagnoses
1. Functional Constipation with Encopresis (Most likely)
o Painful large stools
o Withholding behavior
o Overflow incontinence
o Palpable stool mass
2. Hirschsprung Disease
o Less likely given normal infancy stools and normal growth
3. Anal fissure
o Could contribute to withholding but no fissure seen
4. Celiac Disease
