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
- Medical Conditions: Certain underlying health conditions can cause constipation, such as hypothyroidism, diabetes, neurological disorders (e.g., Parkinson's disease, multiple sclerosis), and structural issues in the colon.
- Psychological Factors: Stress, anxiety, and depression can impact gut function.
Based on R.H.'s case, here are some recommendations I would give to her, drawing on general knowledge of managing constipation:
"R.H., I understand how uncomfortable and frustrating constipation can be, especially when it's been a change from your usual routine. It sounds like your system is really slowing down, and we need to help it get back on track.
First, let's look at your diet. Are you eating a good amount of fruits, vegetables, and whole grains every day? These foods are packed with fiber, which acts like a sponge, drawing water into your stool to make it softer and easier to pass. We'll aim for about 25-30 grams of fiber per day. Also, it's really important to drink plenty of water throughout the day – aim for at least 8 glasses, or more if you're active. This helps the fiber do its job.
Second, I know your arthritis has made daily walks difficult, but physical activity is key for keeping your bowels moving. Even gentle movement, like short walks around the house or simple leg exercises while sitting, can stimulate your digestive system. We can talk about pain management strategies for your arthritis that might make it easier to get some movement in.
Third, let's consider your medications. You mentioned taking naproxen for your arthritis and now aluminum hydroxide for heartburn. Both of these medications can contribute to constipation. We'll need to discuss alternatives or strategies to manage their side effects. For example, the aluminum hydroxide could definitely be making your constipation worse.
Lastly, try to establish a regular time for bowel movements each day, perhaps after breakfast, and don't ignore the urge when it comes. If these lifestyle changes aren't enough, we can discuss adding a fiber supplement or a gentle laxative for a short period, but we want to focus on sustainable, natural methods first."
2. Clinical Manifestations Compatible with Constipation Diagnosis
Based on R.H.'s case study, the following signs and symptoms are compatible with a constipation diagnosis:
- Feeling bloated: This is a common symptom when stool is accumulating in the colon, leading to gas and abdominal distension.
- Constipated for the past month: This indicates a chronic change in bowel habits consistent with constipation.
- Going an entire week with only one bowel movement: This frequency (or infrequency) is well below the normal range of 3 bowel movements per week, a classic diagnostic criterion for constipation.
- Very regular all of her life, having a bowel movement every day or every other day: This highlights a significant and recent deviation from her baseline, indicating a new onset of constipation.
- Straining most of the time: This is a key symptom of difficult defecation, often associated with constipation.
- Often takes her 10 minutes at a minimum to initiate a bowel movement: Prolonged time to initiate defecation signifies difficulty and incomplete evacuation, characteristic of constipation.
- Stools have been extremely hard: Hard stool consistency is a hallmark of constipation, making passage difficult and uncomfortable.
Signs and symptoms not present on the case study that could also be associated with constipation include:
- Abdominal pain or cramping: While she reports bloating, she doesn't explicitly state pain, which can be a common feature of severe constipation.
- Rectal bleeding: This can occur due to straining, leading to hemorrhoids or anal fissures.
- Fecal impaction: In severe, chronic cases, stool can become hardened and lodged in the rectum, leading to leakage of liquid stool around the impaction (encopresis) or complete inability to pass stool.
- Loss of appetite/nausea: Severe constipation can sometimes lead to reduced appetite or feelings of nausea.
- Rectal pressure or fullness: A constant sensation of needing to have a bowel movement, even after attempting.
3. Constipation and Anemia
Based on the information provided in R.H.'s case study, I would NOT consider the possibility of anemia being an associate diagnosis or complication of her constipation at this time.
The key reason is that she reports a recent colonoscopy was negative for tumors or other lesions. A negative colonoscopy rules out the most common and significant cause of anemia associated with changes in bowel habits in a 74-year-old: gastrointestinal bleeding from colorectal cancer or other structural lesions. While severe straining from constipation could theoretically lead to minor hemorrhoidal bleeding, which might contribute to anemia over a very long time, it's not typically the primary cause of clinical anemia, and her negative colonoscopy is reassuring.
Therefore, without any reported symptoms like fatigue, pallor, dizziness, or a history of occult blood in stool, and given the recent clear colonoscopy, anemia is not a high suspicion based solely on the provided information related to her constipation.
C.B. Case Study Analysis
1. DM Prevalence in Race/Ethnic Groups and Compatible Signs/Symptoms for C.B.
Diabetes Mellitus (DM) prevalence varies significantly across different race and ethnic groups. In the United States, American Indians/Alaska Natives, Black (non-Hispanic), and Hispanic/Latino populations have a higher prevalence of diagnosed diabetes compared to non-Hispanic White individuals.