Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint: Briefly describe the patient’s main reason for this visit. This could include:
Constipation (chronic or episodic)
Abdominal distention or bloating
Ribbon stools or fecal incontinence
Delayed passage of meconium (in newborns)
Poor weight gain or growth failure (in infants and children)
History of Present Illness:
Age at onset of symptoms
Frequency and severity of constipation
Characteristics of stools (consistency, caliber)
Presence of abdominal pain or vomiting
Any recent changes in symptoms or bowel habits
Feeding history (if infant)
Past Medical History:
Previous surgeries (exploratory laparotomy, colostomy)
Comorbid conditions (intestinal infections, hypothyroidism)
Medications (laxatives, antibiotics)
Prenatal history (if newborn) – maternal health during pregnancy
Family History:
History of Hirschsprung disease in first-degree relatives
Social History:
Diet (formula feeding history in infants, fiber intake)
Toilet training history (if applicable)
Physical Examination:
General appearance (signs of malnutrition, abdominal distention)
Abdominal exam:
Distention, tenderness
Palpable stool masses
Rectal exam:
Tone (lax or tight)
Digital rectal stimulation – presence of stool and ease of passage
Laboratory Tests:
Electrolytes – to assess dehydration (may occur with chronic constipation)
Thyroid function tests (hypothyroidism can mimic constipation)
Imaging Studies:
Abdominal X-ray (may show signs of fecal impaction)
Abdominal ultrasound (may show dilated colon)
Barium enema (gold standard for diagnosis, demonstrates transition zone between aganglionic and normal colon)
Diagnosis:
Suspected Hirschsprung disease (if workup ongoing)
Confirmed Hirschsprung disease (specify rectosigmoid, colonic, or total colonic involvement)
Treatment Plan:
Surgical intervention (usually staged):
Pull-through procedure (removes aganglionic segment and connects healthy colon to rectum)
Colostomy (temporary diversion for decompression)
Bowel management program (preoperatively and postoperatively)
Dietary modifications (high fiber intake)
Prognosis:
Discuss long-term outlook after surgery and potential need for future bowel management
Importance of regular follow-up
Patient Education:
Explain Hirschsprung disease and the cause of constipation
Importance of following bowel management program (if applicable)
Dietary recommendations
Signs and symptoms to watch for (worsening constipation, abdominal pain)
Importance of regular follow-up
Next Follow-up:
Schedule for the next appointment to monitor progress, address any concerns, and assess need for further management.