HPI Max King is a 4-years Old Caucasian male child visited the clinic with his father with a complaint of leaking stools in his underwear for the past 3-weeks. Father states that his child had intermittent abdominal pain for 2 years and had experienced hard stools as well. He also reported that his child started having watering stools, 2-3 times in a day for the past 3-weeks. He went further to explained that the abdominal pain usually starts after eating and gets better a few minutes. According to max’s father, he states that his son is picky eater, and do not eat vegetables or healthy. Max is known to love eating fried food and dessert, drink three cups of milks in a day, and do not drink enough water. The father mentioned that max is potty trained, and he denies nausea or vomiting, fever, bleeding with defecation, and headache. He reported of straining when defecating. Physical examination revealed a diffuse tenderness to palpation of the abdomen. Treatment/Management Plan Primary Diagnosis: Encopresis and ICD-10 code: F98.1 • Encopresis sometimes called stool soiling can been defined as an intentional or involuntary movement of stools into the underwear or clothing. It usually occurs in toilet trained children with developmental age that is greater or equals to 4 years. The child usual resist defecation which causes feces to be impacted in the colon leading to constipation, and later followed by leaking watery stool (Colombo et al., 2017). In most cases, it happens because a child has a chronic constipation. Some of the symptoms include the need to have a bowel movement with little or no warning, lose or watery stool, leakage of stool into the underwear, intermittent abdominal pain, constipation, avoiding defecation, and urinary tract infections. In this case Max has all the symptoms of encopresis, and both the subjective and objective data supported the diagnosis with the abdominal x-ray that showed impacted large stools in the colon. Differential Diagnosis • Celiac disease – K90.0: This is a genetic autoimmune reaction to eating gluten, a protein found in wheat, barley, and rye, which can affect the gut, and other organs (Wolters Kluwer Health., 2016). Some of the symptoms includes diarrhea, constipation, nausea, vomiting, and weight loss. Max had diarrhea, constipation but there is no report of weight loss, nausea, vomiting, or eating any food that has gluten. The text did to rule out, were negative for celiac disease. So, celiac disease is not the primary diagnosis. • Hypothyroidism- E03.9: This is a condition whereby the thyroid gland do not produce enough of thyroid hormones. Some of the symptoms are fatigue, constipation, and dry skin. Though, max has had constipation, but never complain of fatigue or skin dryness, and thyroid function test where negative. So, we rule out hypothyroidism as the primary. • Constipation- K59.00: dissatisfying excretion of feces mark by infrequent stools, difficult stool passage or both. Some of the characteristics include less three bowel movements a week, hard stools, excessive straining, prolonged time spent on the toilet, a sense of incomplete evacuation, hard or small stools, difficulty passing feces, and abdominal discomfort, such as pain, and bloating. This seems to be the diagnosis but based on the subject and objective information gathered constipation only do not soil pants and underwear. This should be a supporting diagnosis. Additional Laboratory and diagnostic tests: • UA/Urine culture to check for UTI/glucosuria. • Thyroid function tests: hypothyroidism • Abdominal x-ray to check for stool impaction: Result showing a large amount of stool filling the rectum and sigmoid colon. • Antigliadin antibodies (IgA, IgE, IgG): Use to diagnosed celiac disease. • Electrolyte panel including calcium to check for hypokalemia, hypercalcemia, or hyperglycemia. Consults/Referrals. • Nutritionist for dietary management. • Counseling, and behavioral therapy may be considered due to parents’ divorce which may be a contributing factor. Therapeutic Modalities Pharmacological management/treatment: • Dis-impaction with polyethylene glycol. 1.5g/kg/day, orally, daily for 3 days, and maintenance dose of 0.8g/kg/day orally, daily, for six months. Non-Pharmacological management: • Dietary changes by eating enough vegetables, eating healthier and drinking adequate water until he sets up his regular bowel movement. • Continuation of toilet training until the successful maintenance of a regular bowel movement. • Eating high fiber diet, fresh fruits, and fluid intake of 2000 to 3000ml/day if not contraindicated. • Being physical active