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Increase oral hydration and fiber intake
15%
7/47
Check the stool for fecal red blood cells and leukocytes
6%
3/47
Perform a stool culture
0%
0/47
Begin treatment with ciprofloxacin
Begin cognitive behavioral therapy
77%
36/47
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This child is presenting with supposed illness only at school that resolves when he is brought home. Given his age and the transiency of his symptoms, the most likely diagnosis is separation anxiety which is best treated with cognitive behavioral therapy and family therapy. Separation anxiety is typically found in school age children and is associated with anxiety and potentially other symptoms when the child is separated from their primary caretaker. In this case the child has abdominal pain only at school, yet his symptoms resolve when he is at home. It is highly likely that the child is feigning symptoms and altering his behavior as a result of being separated from his caretaker. The next best step in management would be CBT and family therapy to help this child cope. When approaching this question it can be difficult diagnosing separation anxiety given that anxiety was never mentioned in the question stem (and may not be on Step exams). However ruling out other incorrect answers is paramount if you are unsure what the diagnosis is. The child demonstrates vitals within normal limits, a normal physical exam, and normal stools suggesting that there is not an infectious etiology. Moving forward, it is important to note when the symptoms occur, and for some reason they seem to occur when the child is at school, yet the mother notes that the symptoms are absent when at home. This is a prime example of a child feigning illness in order to avoid being separated from their caretaker. Other symptoms can include anxiety, and fear that were not portrayed yet are also classic. Incorrect Answers: Answer 1: Increasing oral hydration and fiber intake is the first treatment when the diagnosis is irritable bowel syndrome. In these patients you must first do a stool guiac and stool white cells, ova and parasite exam as well as a stool culture. Then you must do an abdominal CT and a colonoscopy. All of these tests must come back negative. After lifestyle interventions, other drugs such as dicyclomine or hyocyamine (anti-cholinergic, anti-spasmodics), and TCA's can be used. In this patient, there were no symptoms of abdominal pain that fit the description of irritable bowel, but the most important differentiating factor was that the symptoms did not exist while at home. Answers 2 - 3: If an infection were suspected then the next best step would be fecal leukocytes and RBC's. If these tests came back positive then it would suggest an infectious etiology. The next step after this would then be a stool culture to find a specific organism. It may be arguable that this would be the next step, but it is unlikely that the child has an infection given the normal lab values with no leukocytosis, and the child's very normal bowel movements and abdominal exam. Answer 4: Treatment with a fluoroquinolone is indicated in severe cases of diarrhea which this child does not have. Severe symptoms can include blood, fever, unstable vitals and abdominal pain all of which are negative in this child. This answer is correct if asked what is the best initial therapy in a patient with severe diarrhea. Children who suffer from anxiety disorders such as separation anxiety may have issues in other areas of their lives as well. When children with anxiety disorders are confronted with ambiguous situations that tend to have more negative cognitions toward the situation and tend to underestimate their ability to cope with negative situations (1).
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