Question 1: What are the differential diagnoses?
Question 2: How would you approach and manage this patient?
Drug Discussion: What are the medications available for constipation? What are the drugs' mode of action and common side effects?
This is an example for answering the questions in this blog. You can copy and paste this template adjusting where ever relevant.
You may put one or more drugs that you know of in the drug discussion question. Answers for the drug discussion can be found on the MIMS website.
Question 1: What are the differential diagnoses? | According to Murtagh, the differential diagnoses of chronic constipation are: 1. Probability diagnosis: a. Simple constipation b. Low fibre diet and bad habit 2. Serious disorder not to be missed a. Intrinsic neoplasia: CA colon, rectum or anus b. Extrinsic malignancy: Lymphoma, ovarian CA c. Hirschsprung’s (children) 3. Pitfalls (often missed) a. Impacted faeces b. Local anal lesions c. Drug/ purgative abuse d. Hypokalemia e. Depressive illness f. Acquired megacolon g. Diverticular disease h. Rarities: i. Lead poisoning ii. Hypercalcemia iii. Hyperparathyroidism iv. Dolichocolon (large colon) v. Chaga’s disease vi. Systemic sclerosis 4. Seven masquerades checklist: a. Depression b. Diabetes (rarely) c. Drugs d. Anemia (under nutrition) e. Thyroid (hypo) f. Spinal dysfunction (severe only) g. UTI (usually chronic constipation causes UTI as a result of urinary retention caused by the hard faeces ) 5. Is the patient trying to tell me something? a. May be functional i. Depression ii. Anorexia nervosa *Drugs: opiate analgesics, antidiarrheal agents, anticholinergic agents, antihistamines, antiparkinsons drugs, BDZ, barbiturates, cough mixtures, muscle relaxants, CCB (Verapamil), Tricyclic antidepressants, diuretics (that causes hypokalemia) |
Question 2: How would you approach and manage this patient? - By taking relevant history, performing relevant examination and formulating a relevant management plan | 1) Relevant history: History of presenting illness (HOPI) · Start with Introducing yourself and clarifying patients name, age and occupation · Followed by open ended question (What bought you to clinic today? How can I help you?) · Proceed with close ended question: 1. How long have you had the constipation 2. Bowel habit: Frequency of BO and bowel consistency, any PR bleed/ mucus 3. Any alternating diarrhea 4. Any UTI symptoms 5. Any Abdominal pain? If yes, what is the pain like, pain score, where is the pain, any radiation of the pain? Relieving and aggravating factors or associated sx 6. Dietry history 7. Ssx of Hypothyroidism, Depression 8. Dhx – TRO any drugs that cause constipation · Systemic Review: (Top to Toe) CNS : Fits, Faints, Funny turns (headache/ weakness) RS/ CVS: Chest pain, SOB, Palpitation Abdo: Abdominal pain, BO – any problem passing motion, PU – any urinary problem Muskuloskeletal – Joint pain, Joint swelling, Muscular pain Female – LMP, menses, Menopause · PMH/ PSH · SH Married/ Single/ Divorced Lives in Unemployed/ Work as Smoking: cigarettes/ day Alcohol: Illicit drugs: Diet: Exercise: · DH Allergies: Medications: Name, Dose, Frequency, Duration, Side effects/ problems Traditional medications: Name, duration · FH (need TRO pTB, DM, HPT, BA, IHD, Dyslipidaemia, Premature CVD in the family) Mother: (Alive and well? or passed away at ?age due to what reason) Father : (Alive and well? or passed away at ?age due to what reason) Siblings: (How many siblings, all well?) Children: (How many children, all well?) · ICE (Give example of questions on how to elicit the ICE) I – Do you have any idea what might be the cause of the constipation?C – Is there anything in particular that you are worried about with regards to the constipation? E – Besides getting treatment for your constipation, is there anything else that you would like us to do for you ? 2) Relevant examinations: - General Observation (Go): Hydration status, alert, pink, cahectic/ overweight, poor eye contact (depression) - Vital signs (Vit): BP, P - Relevant Systematic examination approach Radial pulse: bradycardia (hypothyroidism) or tachycardia (anemia) Eyes: pallor Abdomen: Mass PR: Mass, TRO Hirschprung’s disease in children 3) Appropriate management which should include the PLIMA: - Patient Education: Inform the likely diagnosis from the history. May need further investigations TRO other causes of constipation - Lifestyle Changes: increase fluid, fibre and fruits such as banana, papaya (FFF), Exercise - Investigations: B(bloods): TFT, PTH, FBC (Hb), Tumour markers (CA 125, CEA), electrolytes U (urine): UFEME (if pt have ssx of UTI) R (radiology): plain AXR, CT abdomen O (others): - - Medications: Refer to Drug Discussion - Appointment/ Safety Netting: Arrange for appointment to review the symptoms after adopting the lifestyle changes and taking medications prescribed and also to review the results of investigations. vomiting and NBO or no flatus passed (ssx of intestinal obstruction) |
Drug Discussion 1: Lactulose
Generic Name | Lactulose |
Route of Administration | Oral, Syrup |
Dose/Freq | Adult 15ml TDS/ PRN (max dose 45mls) |
Side effects | Diarrhoea (dose-related), nausea, vomiting, hypokalaemia, bloating and abdominal cramps. Potentially Fatal: Dehydration and hypernatraemia on aggressive treatment. |
Contraindications | Galactosaemia, intestinal obstruction. Patients on low galactose diet. |
Pregnancy category | Category B |
Special Precautions | Monitor electrolyte imbalance. Lactose intolerance; diabetics |
Mode of action | Lactulose promotes peristalsis by producing an osmotic effect in the colon with resultant distention. In hepatic encephalopathy, it reduces absorption of ammonium ions and toxic nitrogenous compounds, resulting in reduced blood ammonia concentrations. Onset: 48 hr. Absorption: Not appreciable (oral). Metabolism: Via colonic flora to lactic acid and acetic acid. Excretion: Faeces, urine (as unchanged drug). |
Administration | May be taken with or without food. (May be taken with meals to reduce GI discomfort.) |
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