Constipation

1. HPI

1.1. CC: "I have been struggling with constipation and stomach aches for the last few months".

1.2. 32 y.o. Caucasian female presenting with c/o constipation and abdominal pain.

1.3. No BM x4 days. Previous normal bowel pattern was once daily to every other day.

1.4. Currently having 2-3 movements a week. BMs are hard and pebble-like with occasional mucus noted.

1.5. Abdominal pain starts a couple of hours after eating. Described as crampy and located in LLQ. Occasional nausea with pain, but denies vomiting.

1.6. Abdominal pain improves after passage of stool.

1.7. Increased abdominal bloating and flatulence over past 3 months.

1.8. Has tried OTC Gas-X with minimal relief. Also uses OTC Correctol with moderate results. Has also increased water intake. Warm bath or heating pad also bring some relief.

2. Differential Diagnoses

2.1. Irritable bowel syndrome with constipation: Abdominal pain, pain relieved by defecation, constipation, symptoms occurring over last 3 months

2.2. Inflammatory bowel disease - - Ulcerative colitis: Abdominal pain, pain with defecation, constipation - Chron's Disease: abdominal pain, constipation, occasional mucus in stool, nausea

2.3. Celiac Disease: Constipation, abdominal pain, nausea, distended abdomen

2.4. Ruled out - - Ulcerative colitis: No weight loss, blood in stool, fevers, diarrhea - Chron's disease: No diarrhea, fevers, weight loss, fatigue, vomiting - Celiac disease: Unlikely r/t new onset and patient's age (most usually discovered in childhood), no weight loss - Colorectal cancer: No rectal bleeding, negative occult blood, fatigue, weight loss, no family history

2.5. Colorectal Cancer: Change in bowel habits, abdominal pain

3. Management

3.1. Non-Pharmalogical: Increase fiber and water intake. Increase physical activity. Consider psychological therapy or meditation to assist with stress management.

3.2. Pharmacological: Laxatives (such as lactulose, Milk of Magnesia, and polyethylene glycol with PEG) as preferred choice r/t lesser side effects.

3.2.1. Stop taking laxative if experiencing any severe bloody diarrhea, rectal bleeding, worsening abdominal pain.

3.2.2. If laxatives not helping with increasing frequency and consistency in bowel movements another medication may need to be prescribed to you (such as lubiprostone, linaclotide, or plecanatide).

3.3. Return to office for a follow-up visit if not experiencing any relief with laxatives or if symptoms worsen.

3.4. No referrals currently necessary. However, follow-up with a gastroenterologist may be indicated if having <1 stool per week. If this occurs please call our office so we can follow-up and set you up with a referral.

4. Diagnostics

4.1. CRP - To assess for inflammation and r/o IBS - Results unavailable in office same day

4.2. CBC - To assess for anemia - Results unavailable in office same day

4.3. Occult blood - Negative in office

4.4. Anti-tissue Transglutaminase Antibody - To r/o Celiac Disease - Results unavailable in office same day

4.5. Diagnostics needed to r/o differentials. Diagnosis of IBS in this patient can be made without diagnostic testing r/t symptoms alone

5. Subjective

5.1. PMH: No significant past or current medical issues. Denies hospitalizations, major injuries, or surgeries.

5.2. Current medications: Multivitamin, 1 tablet daily. OTC Gas-X, 2 tablets daily PRN for gas. OTC Correctol laxative, 1 tablet daily PRN for constipation.

5.3. Allergies: No known drug, food, or environment allergies.

5.4. Family hx: Only child. Father: 55y.o. no significant medical hx. Mother: 54y.o. Hx of "spastic colon" since age 20.

5.5. Social hx: Married. FT nurse. Not regularly exercising anymore r/t new baby. Feels safe at home. No abuse suspected. Denies alcohol, drug, and tobacco use. Uses seatbelts regularly. General diet. Approximately 68oz water daily.

5.6. GYN hx: G1P1: 8/18/2019. SVD. Currently breastfeeding.

5.7. ROS: General: Denies weight changes, fevers, chills, fatigue, or malaise. Respiratory: Denies cough, wheezing, or dyspnea. Cardiovascular: Denies chest pain, SOB, or palpitations. Gastrointestinal: C/o significant constipation, intermittent abdominal cramping/discomfort in LLQ, nausea, abdominal bloating, and gas. Denies vomiting, diarrhea, heartburn, dysphagia, or bloody stools. Rectal: C/o occasional painful spasms during straining while having BM. Denies hemorrhoids or rectal bleeding. Psych: Admits to stress r/t new baby and starting nurse practitioner program.

6. Objective

6.1. Height: 5 ft. 6 in. Weight: 167 lbs. BMI: 27 General: Well-developed, 32 y.o. Caucasian female who appears stated age. No acute distress. Vitals: T-98.6 P-68 R-18 BP-122/67 O2-98%

6.2. Heart: PMI non-displaced. S1 and S2. No S3, S4 or murmurs. Rhythm is regular. No peripheral edema, cyanosis or pallor. Capillary refill less than 2 seconds. No carotid bruits. Lungs: Chest expansion symmetrical. Clear to auscultation bilaterally. No adventitious breath sounds noted. GI: Hypoactive bowel sounds x4 quadrants. Soft and nontender on palpation. Slightly distended. No guarding or rebound. No masses. Negative on psoas and obturator signs and no rebound tenderness noted. Liver found in right midclavicular line, edge smooth and palpable 1 cm below right costal margin. Spleen and kidney not palpable.

6.3. Rome IV Screening: + Recurrent abdominal pain at least 1 day/week during previous 3 months + Pain related to (and improved after) defecation + Change in stool frequency + Change in stool form and appearance

7. Diagnosis

7.1. Irritable Bowel Syndrome with Constipation