Chronic Constipation, Coursework Example

Subjective Data

Chief Complaint: Chronic Constipation

History of Present Illness: 17 year-old Caucasian female who presents to the clinic for abdominal pain that has been previously diagnosed as constipation. The patient reports that she has experienced the pain on and off over the past six months, indicating a chronic recurrence. The patient has been using over-the-counter products, such as stool softeners, as treatment; this method demonstrated reduced efficacy over time. Patient reports a well-balanced diet. Reports of occasional urinary incontinence.

Medications:

OTC Ducolax 100 mg as needed

Vesicare 10 mg once a day

Nuvaring insert once a month

Immunizations: Up to date. Flu shot in October 2013

Family History: Her father has hypertension and diabetes. Her mother has hypothyroidism and osteoporosis. Her maternal grandmother had breast cancer. Her paternal grandmother had diabetes and her paternal grandfather had lung cancer. She has two younger sisters, both of which have ADHD. She is single and has no children.

Allergies: Indoor and outdoor allergies. Indoor: dust, lavender scented products. Outdoor: pollen, lavender plant.

Past Medical History: Seasonal allergies, asthma, sprained right ankle.

Past Surgical History: Cosmetic surgery on earlobe to fix rip.

Personal/Social History: Tried smoking cigarettes at age 15. Smoke 3 cigarettes daily, but quit at age 16. Denies alcohol use. Denies recreational drug use. Exercises regularly (running) and follows a special diet before running races that is high in carbohydrates.

Review of Symptoms:

General: Average weight, fatigue, no recent weight change or loss, no fever, or weakness

Skin: Mild acne, no rashes, soreness, mumps, itching, or dryness

Eyes: Wears reading glasses, no changes in vision, no pain, no vertigo, no dryness

Ears: No hearing loss, no ear pressure, no tinnitus

Nose: Occasional allergy symptoms including nasal discharge and congestion

Throat: No sore throat, no hoarseness, gums are regular color, no dry mouth

Neck: Supple, without lymphadenopathy or thyromegaly

Respiratory: Occasional cough, no hemoptysis, no wheeze

Cardiovascular: No palpitations, chest pain, edema, shortness of breath. Regular systolic and diastolic blood pressure

Gastrointestinal: Occasional nausea in mornings, abdominal pain, strain during bowel movement, constipation

Endocrine: Normal A1C reading

Objective Data

T: 37 degrees Celsius (oral)

BP: 105/65

P: 90

RR: 15,

Wt: 50 kg Height: 160 cm

BMI: 19.5 (normal weight)

Normal skin color, normal weight, good posture.

Gastrointestinal: Colonoscopy demonstrated blockage of the colon, supported by barium tests that are indicative of blockage in the lower GI

Endocrine:  Thyroid-stimulating hormone (TSH) assay and Thyroxine (T4) measurement provide evidence of low level of thyroid function

Abdominal: Signs of distension in the ascending, descending, and sigmoid segments of the colon

Differential Diagnoses

1. Hypothyroidism: hypothyroidism is a cause of constipation and is usually associated with fatigue. Since blood tests showed the patient had an underactive thyroid for her age group, this is a potential cause of her chronic constipation and more tests should be conducted in order to confirm this (Maciel et al., 2013).
2. Colon cancer: the abdominal pain that the patient is experiencing is consistent with pain reported by individuals who have colon cancer. The colonoscopy defined blockage in the lower GI and this was confirmed using the barium test. It is essential to determine the identity of this blockage, and whether it is malignant or benign and the best methods to remove it (Mori et al., 2013).
3. Overuse of laxatives: Over time, constant use of laxatives (stool softeners) weaken the bowel muscles. If the patient has been overusing the laxatives, then she will have a reduced muscular ability to move her bowels (Roerig, 2010).

Plan

Endocrine: Take levothyroxine (T4) by mouth once a day. In one month, return to the clinic for a repeat thyroid-stimulating hormone (TSH) assay and thyroxine (T4) measurement. It is expected that T4 levels will increase to normal. A thyroid ultrasound will be performed to determine the cause.

Gastrointestinal: The gastrointestinal blockage will be biopsied. The malignant status of the blockage will be determined and the patient will be contacted to schedule surgery if necessary. At this point, a further plan of treatment will need to be developed.

Rectal: The patient will be asked to limit her use of laxatives to once or twice daily. In addition, she will be asked to keep a journal of when she feels the need to move her bowels but cannot. After two weeks of assessment, this journal will be used in conjunction with her reexamination data to determine if the over the counter drugs should be replaced with prescription drugs and if the muscle movement could be restored (Burness et al., 2014).

Health Promotion: The patient will be asked to follow a high fiber diet and reduce the amount of carbohydrates she consumes for running. She will also be asked to keep a food journal so the exact amount of fiber she consumes could be track and suggestions made on this basis.The patient should return in two weeks for a follow-visit.

Reflection Notes

In this situation, I agree to the plan of care. Currently, it is difficult to determine the exact cause of the chronic constipation, although hypothyroidism, colon cancer, and misuse of laxatives are all excellent candidates. It is also necessary to consider that the patient may be suffering from a combination of two or more disorders. Whether or not the constipation is a result of the patient’s hypothyroidism, it is clear that this is a health issue for the individual and she should be taking medication to compensate for her low hormone levels. After her follow-up in two weeks, she should take care to schedule regular appointments until we have enough long-term data about her condition to make a definitive diagnosis. It is important to sort out her complex symptoms before taking extensive action to prevent against mistreatment.

References

Burness CB, Keating GM. (2014). Oxycodone/Naloxone Prolonged-Release: A Review of Its   Use in the Management of Chronic Pain While Counteracting Opioid-Induced Constipation. Drugs. [epub].

Maciel LM, Kimura ET, Nogueira CR, Mazeto GM, Magalhães PK, Nascimento ML, Nesi-França S, Vieira SE. (2013). Congenital hypothyroidism: recommendations of the Thyroid Department of the Brazilian Society of Endocrinology and Metabolism. Arq Bras Endocrinol Metabol, 57(3):184-92

Mori H, Tsushimi T, Kobara H, Nishiyama N, Fujihara S, Matsunaga T, Ayagi M, Yachida T, Masaki T. (2013). Endoscopic management of a rare granulation polyp in a colonic diverticulum. World J Gastroenterol, 19(48):9481-4.

Roerig JL. (2010). Laxative abuse: epidemiology, diagnosis and management. Drugs, 70(12):1487-503.