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Constipation History ♯2

PATIENT INFORMATION

Wendy is a 35-year-old lady who comes to your GP practice complaining of constipation. You are the final year medical student on your GP placement and you have been asked to see her.

CANDIDATE INSTRUCTIONS

You will have 8 minutes to perform the following:

  1. Take a history from the patient based on their presenting complaint (6 minutes).
  2. Outline which investigations would you order for Wendy (1 minute).
  3. Outline your management plan to the examiner (1 minute).

History of presenting complaint

Opening statement:

“Hi Doc, I’ve been really constipated lately, I haven’t opened my bowel in 5 days.”

  • What: constipation, last stool very hard, painful to evacuate
  • When: has been troubling her for last few days, last opened bowels 5 days ago
  • Time course: first time constipated like this, usually opens bowels every 2 days
  • Quality: looked like little pebbles, even had some blood on wiping
  • Severity: feel like I had to strain a lot with last bowel motion
  • Alleviating/aggravating factors: have tried sitting on the toilet and drinking hot water, no help. Haven’t tried anything else (e.g. laxatives)
  • Beliefs: “Feels like my backend is blocked”

Systems review/risk factors

Symptoms in BOLD indicate positive answers, other answers are suggestions of what is required in terms of questioning.

Gastrointestinal:

  • Abdominal pain: no pain, but feel uncomfortable
  • Bloated: yes, abdomen seems bigger
  • Diarrhoea: no
  • Nausea: no
  • Vomiting: no
  • Fatigue: no
  • LOW: no
  • LOA: no
  • Blood in stools: only on wiping, bright red, very little
  • Tenesmus: (feeling like you need to pass stool but nothing comes out): yes

Any recent changes in the last 5 days? (Look for cause of constipation)

  • new medications, changes to routine, stress, recent surgery

Urinary symptoms:

  • Urinary incontinence: no
  • Fluid intake: normal, around 2 L water, 1 tea, 2 coffee

Endocrinology

  • Hypothyroidism symptoms: constipation, weight gain, dry skin, intolerance to cold, hair changes/loss, mood changes
  • Hypercalcaemia symptoms: constipation, renal stones, mood changes/psychiatric symptoms, abdominal pain, bone pain

Past medical history

  • Medical: mild iron deficiency anaemia
  • Surgical: Had a Lap cholecystectomy 8 days ago – went well
    • DC D4 post op, nil complications
    • still taking pain meds everyday regularly
    • not discharged with laxatives, BO once in hospital

Medications

  • No usual
  • Current prescription: endone 5 mg PRN
    • Have you been using the endone? Yes every day; up to 4 times
  • Vit D, iron tablets (prescribed by GP for mild IDA)

Allergies

  • NKDA

Family history

  • Father: T2DM otherwise well
  • Mother: no health issues
  • Ask specifically for Hx of Bowel Ca: nil

Social history

  • Occupation: Tram driver
  • Home with husband and 6-year-old
  • Exercise: can walk miles
  • Diet: takeaway 1-2x week, not always enough vegetables but I try. I have steak/ meat regularly.
  • Smoker: 10/d when stressed x20y
  • Occasional alcohol

Outline what investigations you would like to do for this patient.

As cause is quite clear in this case can be a clinical diagnosis, but if wanted to confirm diagnosis/establish cause could consider

  • Bloods: FBE, Iron studies, TFTs, CMP
  • Imaging: could consider AXR to confirm constipation, but not readily indicated unless initial treatment fails

Outline your management plan to the examiner

Lifestyle:

  • Increase diet fibre and fluid
  • Exercise: movement can help stimulate the bowels

Medical

  • Cease Endone if pain now well controlled, could use simple analgesics (paracetamol, ibuprofen instead)
  • Laxative, options include
    • Stool softener: docusate sodium (colace)
    • Bulk forming laxatives: Metamucil
    • Osmotic laxatives: lactulose
    • Stimulant: Senna (Senokot), bisacodyl
    • Suppository: Glycerol

If severe may need manual disimpaction/evacuation

Total:

NOTES

Characteristics of constipation:

  • Infrequent stool passage (< 3/ weeks)
  • Passage of hard stools
  • Straining > 25% of the time
  • Incomplete evacuation
  • Sensation of anorectal blockage

Aetiologies:

  • Low fluid and fibre diet, lack of exercise, poor mobility, poor toilet training
  • Pregnancy
  • Endocrine – DM, hypothyroidism, hyperparathyroidism
  • Neurological – Parkinson’s disease, spinal cord disorders
  • Drugs – opioids, anti-muscarinics, iron tablets
  • Colon disorders – strictures, anal fissure, aganglionosis, diverticulosis, colorectal cancer
  • IBS

Examination

  • Growth (in children)
  • Abdo: distension, faeces, organomegaly, abdo hernias
  • Anal/DRE: skin tag, fissure, placement of anus, anal wink/tone
  • Back/spine/neuro exam

Complications of Constipation:

  • Haemorrhoids
  • Anal fissure
  • Urinary retention
  • Faecal incontinence/overflow
  • diarrhoea

REFERENCES

Better Health: https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/constipation