Constipation Notes - Patient Identification

Patient identification Name: MRS YY Age: 70 years Gender at birth: Female Gender identity: Female Source: the patient and daughter Allergies: NKFDA Current medication: Allugel syrup 10mls PMH: Positive for chronic illness. PUD Immunization: Influenza vaccine 2 years ago Preventive care: colonoscopy levels 3 years ago. Negative for colon cancer Surgical history: hysterectomy 15 years ago Family history: She is the first born, with 3 other siblings, and all are alive and wellFather deceased at 85 years due to Hypertension and heart complications Mother is also deceased at 75 years old, due to arthritis Social history: retired positive for alcohol consumption negative for cigarette consumption. Married with 2 children, all live and well Sexual orientation: straight Nutritional history: no allergies SUBJECTIVE HISTORY Chief complaint (CC) 1. < Passing hard stool= 2. < Straining to pass stool= SYMPTOM ANALYSIS/HPI The patient is a 70 year old woman who came to our clinic having problems passing hard stool for 2 weeks continuous. She complained of the feeling of straining to pass stool and that scares her to go the bathroom. Her frequency of passing stool has therefore reduced. It started 2 weeks ago after celebrating her 70th birthday. Symptoms are aggravated eating fatty meals and relieved by taking plenty of water. Over-the-counter painkillers and application gels resulted in no improvements. REVIEW OF SYSTEMS (ROS) CONSTITUTIONAL: the patient reports a pain score of 3/10. Denies weight loss or body weakness NEUROLOGIC: reports occasional headache and dizziness no report of seizures. The patient denies changes in the Level of consciousness HEENT: HEAD: normocephalic. The patient denies trauma. EYES: denies changes in vision. The patient reports no changes in vision. EAR: negative for drainage, denies loss or changes in hearing. NOSE: the patient denies the presence of nasal polyps, nasal discharge, or congestion. THROAT: the patient denies pain while swallowing, negative for hoarseness of voice RESPIRATORY: patient denies shortness of breath, and coughing. CARDIOVASCULAR: the patient denies chest pains, palpitations, and fast breathing GASTROINTESTINAL: Negative for abdominal pain, there is mild discomfort reported by the patient, Negative for nausea vomiting, no diarrhea. The patient reports loss of appetite. There is pain in the anal region after a bowel movement. Stoll can be accompanied by blood stains GENITOURINARY: the patient denies genital abnormalities; she also denies abnormal discharge or bleeding MUSCULOSKELETAL: negative for joint pains and muscles pain. No history of fall or injury. Skin integrity is intact. OBJECTIVE DATA VITAL SIGNS: temperature: 99.5F, pulse: 78b/m, BP: 125/70mmhg, RR: 18b/m, SP02: 95% on room air, weight 165lb, BMI: 24.1. Pain score: 3/10 GENERAL APPEARANCE: kempt and well oriented. NEUROLOGIC: alert, CNII-XII grossly intact. Intact sensation on bilateral upper and lower limbs HEENT HEAD: no sign of trauma, symmetric. Non tenderness on maxillary sinuses EYES: Visual acuity and extra ocular eye movements are intact. EARS: the ear canals are patent bilaterally; no edema or exudates. Both tympanic membranes are intact. NOSE; no nose bleeding intact nasal mucosa the oral mucosa is intact with no lesions. NECK: the neck is supple without cervical lymphadenopathy. There is no distention of jugular veins. There is no goiter or thyroid mass. THROAT: no tenderness, no pain while swallowing. No voice hoarseness CARDIOVASCULAR: S1 and S2 present. No murmur. Regular heart rate noted, the Capillary refill< 2 sec RESPIRATORY: there is no tactile fremitus, there is no use of abdominal muscles for breathing. There is no difficulty in breathing; air entry into the lungs is adequate and clear with no friction GASTROINTESTINAL: the oral mucosa is moist and intact; bowel sounds are present and active in all quadrants. Negative for umbilical hernia Abdomen is tender and no pain noted no guarding noted on palpation. No organomegaly noted. There is a surgical scar noted. Rectal examination shows tender and painful anal region, slightly swollen, cracked skin areas with swollen vessels. GENITOURINARY: normal external genitalia observed, no pain no pus or discharge. There is no swelling of the genitalia. MUSCULOSKELETAL: there is full range of motion on all limbs. No joint painwere s notedand , nostiffness noted. The skin is intact with no breakage. ASSESSMENT The patient is a 70-year-old elderly woman who came to our clinic experiencing discomfort and pain passing hard stool for a period of 2 weeks. The symptoms started 2 weeks ago shortly after celebrating her 70th birthday. There is pain and discomfort after passing the stool and sometimes it’s accompanied by bloody stains, drinking plenty of water before going to the bathroom relies on the symptoms, and waiting long hours after the urge worsens the experience. Dobesil-H preparation creams relieve itching MAIN DIAGNOSIS CONSTIPATION (ICD 10 K59.00) Mrs. YY is having constipation, this is a condition of passing hard stool continuously and the rate of bowel movements is reduced. Most common in the elderly and pregnant women (Caffrey & Pensa, 2019) Diagnosis is made from history and physical examination. Abdominal X-rays may also be helpful for the diagnosis. Lifestyle and nutritional modification is the best treatment modality for the condition. Common causes include dehydration and stress. A sudden changes in the environment and routine also may lead to constipation. DIFFERENTIAL DIAGNOSIS 1. CROHNS DISEASE (K50.90)-this is a type of the inflammatory bowel disease that affects the lining of the digestive tract mostly the small intestine and the colon. However, it can affect any part of the digestive tract. It is characterized by vomiting, diarrhea, and abdominal pains (Amer, 2021) Anti-diarrheal and anti-inflammatory drugs are used in the management of the condition 2. APPENDICITIS (ICD 10 K35.80) this is the inflammation of the appendix. The appendix is a finger-shaped organ that projects downwards from the colon on the right side of the abdomen (Amer, 2021) It causes pain that may worsen during coughing. The patient may also experience nausea and vomiting. It is caused by an obstruction of the lining of the appendix causing an accumulation of micro-organisms This diagnosis is made after physical examination, laboratory test, and radiological examination to rule out otherconditions 3. INTESTINAL OBSTRUCTION (ICD 10 K56.60) this is the compression of the GIT which prevents normal passage of digested materials through the bowel. A history of an abdominal surgery can contribute to the problem. Symptoms include abdominal pain, discomfort, and inability to pass stool. It can be managed by avoiding solid foods, surgery, and relieving the pressure in the stomach using a tube (Hamid & Shahid Banday, 2019) PLAN Labs and diagnostic tests to be ordered • Complete blood count for white blood cell count • Abdominal ultrasound, CT scan, • Abdominal erect X-ray (Caffrey & Pensa, 2019). • Rectal exam • Colorectal transit study • Barium enema-X-ray • Colonoscopy PHARMACOLOGICAL TREATMENT • Fiber supplements in the diet such as Fibercon, Metamucil • Osmotic like magnesium citrate, lactitol, and MiraLAX • Bowel stimulants- Dulcolax, bisacodyl (Caffrey & Pensa, 2019) • Stool softener like Docusate sodium • Oral lactulose 10mls thrice a day • Linaclotide caps once daily NON-PHARMACOLOGICAL TREATMENT • Taking plenty of water • Adequate physical exercise • A fiber-rich diet PATIENT EDUCATION • Strict adherence to prescribed medication • Don’t suppress the urge to defecate • Squatting on the toilet may make bowel movement easier • Nutritional support, maintain a healthy diet rich in fiber (Caffrey & Pensa, 2019) • Take plenty of fluids • Avoid alcohol and sedentary lifestyle • When constipation occurs with hemorrhoids, ensure adequate intake of water and stool softener to prevent painful experiences while in the bathroom (Hamid, & Shahid Banday, 2019) FOLLOW-UP/REFERRAL • No referral is needed • Follow-upup review in 14 days to review progress