R.H. is a 74-year-old black woman, who presents to the family practice clinic for a scheduled appointment. She complains of feeling bloated and constipated for the past month, some-times going an entire week with only one bowel movement. Until this episode, she has been very regular all of her life, having a bowel movement every day or every other day. She reports straining most of the time and it often takes her 10 minutes at a minimum to initiate a bowel movement. Stools have been extremely hard. She denies pain during straining. A recent colonoscopy was negative for tumors or other lesions. She has not yet taken any medications to provide relief for her constipation. Furthermore, she reports frequent heartburn (3–4 times each week), most often occur-ring soon after retiring to bed. She uses three pillows to keep herself in a more upright position during sleep. On a friend’s advice, she purchased a package of over-the-counter aluminum hydroxide tablets to help relieve the heartburn. She has had some improvement since she began taking the medicine. She reports using naproxen as needed for arthritic pain her hands and knees. She states that her hands and knees are extremely stiff when she rises in the morning. Because her arthritis has been getting worse, she has stopped taking her daily walks and now gets very little exercise.
Case Study Questions
In your own words define constipation and name the risk factors that might lead to develop constipation. List recommendations you would give to a patient who is suffering from constipation. You might use a previous experience you might have.
Based on the clinical manifestations on R.H. case study, name and explain signs and symptoms presented that are compatible with the constipation diagnosis. Complement your list with signs and symptoms not present on the case study.
Sometimes as an associate diagnosis and a complication, patients with constipation could have anemia. Would you consider that possibility based on the information provided on the case study?
Endocrine Function:
C.B. is a significantly overweight, 48-year-old woman from the Winnebago Indian tribe who had high blood sugar and cholesterol levels three years ago but did not follow up with a clinical diagnostic work-up. She had participated in the state’s annual health screening program and noticed that her fasting blood sugar was 141 and her cholesterol was 225. However, she felt “perfectly fine at the time” and could not afford any more medications. Except for a number of “female infections,” she has felt fine until recently. Today, she presents to the Indian Hospital general practitioner complaining that her left foot has been weak and numb for nearly three weeks and that the foot is difficult to flex. She denies any other weakness or numbness at this time. However, she reports that she has been very thirsty lately and gets up more often at night to urinate. She has attributed these symptoms to the extremely warm weather and drinking more water to keep hydrated. She has gained a total of 65 pounds since her last pregnancy 14 years ago, 15 pounds in the last 6 months alone.
Case Study Questions
In which race and ethnic groups is DM more prevalent? Based on C.B. clinical manifestations, please compile the signs and symptoms that she is exhibiting that are compatible with the Diabetes Mellitus Type 2 diagnosis.
If C.B. develop a bacterial pneumonia on her right lower lobe, how would you expect her Glycemia values to be? Explain and support your answer.
What would be the best initial therapy non-pharmacologic and pharmacologic to be recommended to C.B?
Full Answer Section
- Low Fiber Diet: Insufficient intake of fruits, vegetables, and whole grains can lead to harder stools that are more difficult to pass.
- Dehydration: Not drinking enough fluids can result in the body absorbing more water from the colon, leading to dry and hard stools.
- Lack of Physical Activity: Regular exercise helps stimulate bowel function. Reduced mobility, as seen with R.H. stopping her walks, can contribute to constipation.
- Certain Medications: Some medications, including naproxen (an NSAID), aluminum hydroxide antacids, and others, can have constipation as a side effect.
- Ignoring the Urge to Defecate: Regularly suppressing the urge to have a bowel movement can weaken the signals and lead to constipation over time.
- Changes in Routine: Travel or significant changes in daily habits can disrupt normal bowel function.
- Underlying Medical Conditions: While R.H.'s recent colonoscopy was negative for major lesions, other conditions can contribute to constipation.
- Psychological Factors: Stress and anxiety can sometimes affect bowel habits.
Recommendations for a patient suffering from constipation would include:
- Dietary Modifications: Increase the intake of high-fiber foods such as fruits (especially prunes, berries, and apples with skin), vegetables (leafy greens, broccoli, carrots), and whole grains (oats, bran, whole-wheat bread).
- Hydration: Drink plenty of fluids throughout the day, primarily water. Aim for at least 8 glasses of water daily.
- Regular Exercise: Encourage regular physical activity, even moderate exercise like walking, to help stimulate bowel motility.
- Establish a Regular Bowel Routine: Try to have bowel movements at the same time each day, preferably after a meal when the urge is often strongest. Do not ignore the urge to defecate.
- Proper Toilet Posture: Elevating the feet slightly with a small stool while sitting on the toilet can help align the colon for easier passage of stool.
- Over-the-Counter Remedies (with caution and physician advice):
- Fiber supplements: Psyllium husk, methylcellulose, or wheat dextrin can add bulk to the stool.
- Stool softeners: Docusate can help moisten the stool.
- Osmotic laxatives: Polyethylene glycol (PEG) or milk of magnesia can draw water into the colon. These should be used cautiously and not for long-term without medical advice.
- Stimulant laxatives: Bisacodyl or senna stimulate bowel contractions but should be used sparingly and under medical guidance due to the potential for dependence.
- Review Medications: Discuss all current medications with a healthcare provider to identify if any are contributing to the constipation.
- Consider Probiotics: Some studies suggest that certain probiotics may help with bowel regularity.
- Stress Management Techniques: If stress is a contributing factor, recommend relaxation techniques.
Personal Experience Note: In a previous experience, I advised a patient experiencing mild constipation to increase their water intake and add a serving of high-fiber cereal to their breakfast daily. This simple change, along with establishing a regular time to use the restroom, significantly improved their bowel regularity within a few days.
2. Based on the clinical manifestations on R.H. case study, name and explain signs and symptoms presented that are compatible with the constipation diagnosis. Complement your list with signs and symptoms not present on the case study.
Signs and symptoms presented in R.H.'s case study compatible with constipation:
- Infrequent bowel movements: Reporting sometimes going an entire week with only one bowel movement clearly indicates reduced frequency.
- Lifelong regularity followed by a change: The fact that R.H. has been very regular her entire life until this recent episode strongly suggests a new onset of constipation.
- Straining during bowel movements: Straining is a common symptom as the body tries to expel hard stool.
- Prolonged time to initiate bowel movement: Taking at least 10 minutes to initiate a bowel movement suggests difficulty in passing stool.
- Extremely hard stools: This is a key characteristic of constipation, indicating slow transit time in the colon and excessive water absorption.
- Bloating: Feeling bloated is a common abdominal symptom associated with slowed bowel movements and gas buildup.
Signs and symptoms of constipation not present in the case study (but can occur):
- Abdominal pain or cramping: While R.H. denies pain during straining, some individuals with constipation experience abdominal discomfort.
- Feeling of incomplete evacuation: The sensation that the bowels are not fully emptied after a bowel movement.
- Small, hard, pellet-like stools: This is another common description of constipated stool.
- Nausea or vomiting: In severe or prolonged constipation, these symptoms can occur due to bowel distension and backup.
- Rectal bleeding: Straining to pass hard stools can sometimes cause small tears (anal fissures) leading to rectal bleeding.
- Headache: Some individuals report headaches associated with constipation.
3. Sometimes as an associate diagnosis and a complication, patients with constipation could have anemia. Would you consider that possibility based on the information provided on the case study?
Sample Answer
R.H. Case Study
1. Define constipation and name the risk factors that might lead to develop constipation. List recommendations you would give to a patient who is suffering from constipation. You might use a previous experience you might have.
Constipation, in simple terms, refers to infrequent bowel movements, typically fewer than three per week, that are often difficult to pass. Stools may be hard, dry, and small, and the process of defecation can involve straining.
Several risk factors might contribute to the development of constipation:
- Age: Older adults, like R.H., are more prone to constipation due to slower metabolism, decreased bowel motility, and reduced physical activity.