Pediatrician's note

PATIENT'S NAME: LIAM REYNOLDS DOS: 24/10/2023 DOB: 04/12/16 AGE: 7 years, 6 months, and 12 days. SEX: Male ACCOMPANIED by: Mother (Sarah Reynolds)

SUBJECTIVE

Reason for Visit: Liam's mother brings him in today for evaluation of chronic constipation and intermittent periumbilical abdominal pain.

History of Present Illness: Liam has experienced infrequent, hard, painful bowel movements occurring once every 4 to 5 days for the past 3 months. His stools are large-caliber (Bristol Type 1-2) and occasionally accompanied by bright red blood streaks on the toilet paper. Liam also reports cramping periumbilical pain that improves transiently after defecation, alongside episodes of fecal soiling (encopresis) in his underwear 3 times per week.

ROS: Liam's mother notes a mildly decreased appetite over the past two weeks and occasional postprandial bloating, but he denies fever, vomiting, weight loss, nocturnal diarrhea, or dysuria.

Past Medical History: History of mild infantile eczema and acute otitis media at age 3; no prior surgeries or hospitalizations.

Medication History: Liam currently takes macrogol 3350 (polyethylene glycol 3350, MiraLAX®) 8.5 g PO PRN, though adherence has been inconsistent.

Allergies: NKA.

Immunizations: Liam's immunizations are up-to-date.

Growth and Development: Liam is meeting all age-appropriate developmental milestones and doing well in second grade.

Diet and Nutrition: Liam's diet is high in processed carbohydrates and dairy (~24 oz whole milk daily) with minimal intake of fruits, vegetables, and water.

Family History: Maternal history of irritable bowel syndrome; negative for celiac disease, inflammatory bowel disease, or thyroid disorders.

OBJECTIVE

Growth Parameters:- Wt: 52 lbs, Ht: 48.5 inches

• Vital Signs: T 36.8 °C, HR 88 bpm, RR 18/min, BP 98/62 mmHg, SpO2 99 % on RA

PHYSICAL EXAMINATION

• General Appearance: Active, Alert, Pink, and Nontoxic
• Eyes: Normal eyes, No redness,
• Nose: Normal nasal mucosa, no rhinorrhea or congestion
• Ears: Normal TM with good LR,
• Throat: No redness or ulcers
• Chest/Lungs: No distress, No wheezing or rales
• Cardiovascular: Normal S1 and S2, No Murmur heard
• Abdomen: Soft, mildly distended, palpable mobile fecal mass in LLQ, mild tenderness to deep palpation in LLQ, no HSM
• Skin: Perianal skin intact with a small, healing superficial posterior midline anal fissure at 6 o'clock; no rashes
• Musculoskeletal: Moving all Extremities well
• CNS: Normal tone and reflexes

INVESTIGATIONS

• Abdominal X-ray (KUB) completed on 24/10/2023: Moderate-to-severe fecal loading throughout the colon and rectum without abnormal bowel gas dilatation or free air.
• Point-of-care urinalysis: Negative for leukocyte esterase, nitrites, blood, and glucose.

ASSESSMENT and PLAN

1. Functional constipation with encopresis

• Order celiac disease screening panel (tTG-IgA and total serum IgA) and TSH/Free T4 if no improvement after 4 weeks of compliant therapy.
• Disimpaction protocol: macrogol 3350 (polyethylene glycol 3350, MiraLAX®) 17 g PO BID mixed in 8 oz fluid for 3 days, followed by daily maintenance of 17 g PO QD. Instructed on behavioral modifications including scheduled post-meal toilet sitting for 5–10 minutes with a footstool.
• Refer to Pediatric Nutrition for high-fiber dietary counseling and fluid management.

2. Anal fissure, acute

• Apply white petrolatum (Vaseline®) or zinc oxide barrier cream topically to perianal area QID and after each bowel movement; warm sitz baths for 10–15 minutes BID to promote sphincter relaxation and healing.

-Signed: Marcus Vance MD_________________________________________________________________________

BILLING

• ICD-10 Codes: · K59.04 (Chronic idiopathic constipation) · R15.1 (Fecal smearing / Encopresis) · K60.0 (Acute anal fissure)

• CPT Code for New and Established patient for above visit (apply strict criteria to select a single CPT code for the office visit) · 99214 (Established patient office visit, moderate MDM) · - CPT Code Relevant procedure code · 74018 (Radiologic examination, abdomen; 1 view) · 81002 (Urinalysis, non-automated, without microscopy)