,DIAGNOSTIC SUMMARY AND IMPRESSION: , My impression is that the patient has a long history of constipation and impaction, which has been treated medically, but it would appear that the mother has not followed through consistently with the behavioral component of toilet sitting, increased fiber, regular medication, so that the problem has likely continued. 
,DIAGNOSTIC SUMMARY AND IMPRESSION : , My impression is that the patient has a long history of constipation and impaction , which has been treated medically , but it would appear that the mother has not followed through consistently with the behavioral component of toilet sitting , increased fiber , regular medication , so that the problem has likely continued .