A nurse is assisting with the care of a toddler. Click to highlight the findings that require follow-up. To deselect a finding, click on the finding again.

The findings from today's visit that require follow-up are contained in the second nurse's note. The toddler now appears lethargic, is producing ribbon-like, foul-smelling stools, has a distended abdomen, and has a palpable fecal mass on palpation. Together, these findings are highly concerning for Hirschsprung disease, a congenital condition in which absence of ganglion cells in the colon causes functional obstruction. Ribbon-like stools, foul odor, abdominal distension, a palpable fecal mass, and lethargy in a toddler with a history of chronic constipation that has not responded to conservative management are classic warning signs requiring urgent provider follow-up and further diagnostic workup such as a rectal biopsy. The vital signs from both visits fall within normal ranges for a 13-month-old — heart rate of 120–125/min, respiratory rate of 26–27/min, blood pressure of 88/44–89/42 mm Hg, temperature near 37°C, and oxygen saturation of 98–99% on room air are all expected for this age group and do not independently require follow-up. The initial visit note describing intermittent constipation and hypoactive bowel sounds was concerning but had already been addressed with conservative treatment; it is the worsening clinical picture in today's note that demands urgent attention.