A 4-year-old boy is brought to your office by his mother due to concerns about his bowel habits. The problem started about six months ago when they began toilet training. He passes stools only once every 3 to 4 days. His mother describes the stools as very large, hard, and painful to pass, often causing him to cry and strain. She has recently noticed brown smearing in his underwear. He sometimes complains of vague belly pain, which seems to improve after he has a bowel movement. He has become increasingly resistant to sitting on the toilet. His diet is described as that of a “picky eater,” with a high intake of milk and chicken nuggets, and low intake of fruits and vegetables.

His birth history was unremarkable, and he passed meconium within the first 24 hours of life. He has met all developmental milestones appropriately. His past medical history is otherwise unremarkable. He takes no medications.

The child's vital signs are within normal limits. His growth parameters are around the 50th percentile for age. He appears well and in no acute distress.