Constipation SOAP Note

Constipation SOAP Note – Week 6: Assessment of the Abdomen and
Gastrointestinal System

Patient Information

Initials: J.D., Age: 45, Sex: Female, Race: Caucasian

S. (Subjective)

CC (Chief Complaint):

“I haven’t had a bowel movement in 5 days.”

HPI (History of Present Illness):

J.D. is a 45-year-old Caucasian female presenting with constipation for the past 5 days. Using the LOCATES mnemonic:

• Location: Abdominal discomfort, primarily in the lower abdomen
• Onset: Gradual onset over the past week, with no bowel movement for 5 days
• Character: Patient describes feeling “bloated” and “full”
• Associated symptoms: Mild abdominal pain, decreased appetite, and occasional nausea
• Timing: Constant, worse after meals
• Exacerbating factors: Eating large meals, dairy products
• Relieving factors: None identified; attempted over-the-counter laxatives without success
• Severity: Patient rates discomfort as 6/10

The patient reports a recent increase in stress at work and a decrease in physical activity. She has also been traveling for business, which has disrupted her normal routine.

Current Medications:

• Lisinopril 10 mg daily for hypertension
• Occasional use of ibuprofen for headaches
• Recently started calcium supplements 500 mg daily

Allergies:

No known drug allergies

PMHx (Past Medical History):

• Hypertension, diagnosed 3 years ago, well-controlled with medication
• Occasional tension headaches
• No history of gastrointestinal disorders
• No previous surgeries

Immunization status: Up to date on all recommended adult vaccinations

Soc Hx (Social History):

• Occupation: Marketing executive, recently increased work hours
• Marital status: Married with two children
• Exercise: Usually exercises 3 times a week, but has decreased in the past month due to work demands
• Diet: Reports “eating on the go” more often, with increased fast food intake
• Tobacco use: Never smoker
• Alcohol use: Social drinker, 1-2 glasses of wine per week
• Caffeine intake: 2-3 cups of coffee daily
• Fluid intake: Estimates 4-5 glasses of water daily
• Fiber intake: Admits to low fiber intake in recent weeks
• Stress level: Reports increased stress due to work demands
• Sleep: 6-7 hours per night, sometimes disrupted
• Travel: Recent business trip lasting 5 days

Fam Hx (Family History):

• Father: Hypertension, Coronary Artery Disease
• Mother: Osteoporosis
• No family history of colorectal cancer or inflammatory bowel disease

ROS (Review of Systems):

• General: No fever, chills, or unexplained weight loss
• HEENT: No headaches, vision changes, or oral lesions
• Cardiovascular: No chest pain, palpitations, or edema
• Respiratory: No shortness of breath or cough
• Gastrointestinal: Constipation, bloating, mild abdominal pain, decreased appetite, occasional nausea. No vomiting, no blood in stool, no changes in stool caliber
• Genitourinary: No dysuria, frequency, or urgency
• Musculoskeletal: No joint pain or muscle weakness
• Skin: No rashes or lesions
• Neurological: No numbness, tingling, or weakness
• Psychiatric: Reports feeling more anxious due to work stress
• Endocrine: No polyuria, polydipsia, or heat/cold intolerance
• Hematologic: No easy bruising or bleeding
• Allergic/Immunologic: No recent infections or allergic reactions

O. (Objective)

Physical Examination:

• General: Alert, oriented, in no acute distress. Well-nourished, well-hydrated.
• Vital Signs:
• BP: 128/78 mmHg
• HR: 76 bpm
• RR: 14 breaths/min
• Temp: 37.0°C (98.6°F)
• SpO2: 99% on room air
• BMI: 27.5 kg/m²
• HEENT: Normocephalic, atraumatic. Oral mucosa moist, no lesions.
• Neck: Supple, no lymphadenopathy, no thyromegaly
• Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops
• Respiratory: Clear to auscultation bilaterally, no wheezes, rales, or rhonchi
• Abdominal: Soft, distended, diffuse tenderness to palpation, especially in lower quadrants. No rebound tenderness or guarding. Bowel sounds hypoactive. No hepatosplenomegaly.
• Musculoskeletal: Normal range of motion, no edema
• Skin: Warm, dry, no rashes or lesions
• Neurological: Alert and oriented x3, cranial nerves II-XII intact, normal strength and sensation in all extremities
• Psychiatric: Appropriate affect, mildly anxious mood

Diagnostic Results:

• Complete Blood Count (CBC): Within normal limits
• Basic Metabolic Panel (BMP): Within normal limits
• Thyroid Stimulating Hormone (TSH): 2.5 mIU/L (normal range: 0.4-4.0 mIU/L)
• Abdominal X-ray: Shows moderate amount of stool throughout the colon, no obstruction or free air

A. (Assessment)

Differential Diagnoses:

1. Functional Constipation (primary diagnosis)
   • Justification: Patient’s symptoms, recent lifestyle changes, and physical exam findings are consistent with functional constipation.
   • Evidence: According to the Rome IV criteria, functional constipation is diagnosed when two or more of the following are present for at least 3 months: straining, lumpy/hard stools, sensation of incomplete evacuation, sensation of anorectal obstruction, manual maneuvers to facilitate defecation, or fewer than 3 spontaneous bowel movements per week (Lacy et al., 2016).
2. Irritable Bowel Syndrome with Constipation (IBS-C)
   • Justification: The patient’s symptoms could be consistent with IBS-C, especially given the association with stress.
   • Evidence: The American College of Gastroenterology guidelines state that IBS is characterized by recurrent abdominal pain associated with defecation or a change in bowel habits (Lacy et al., 2021).
3. Medication-Induced Constipation
   • Justification: The patient’s recent start of calcium supplements could contribute to constipation.
   • Evidence: A review in the American Journal of Gastroenterology notes that calcium supplements can cause or exacerbate constipation (Bharucha et al., 2013).
4. Hypothyroidism
   • Justification: While the patient’s TSH is within normal limits, hypothyroidism can cause constipation and should be considered.
   • Evidence: The American Thyroid Association guidelines state that constipation is a common symptom of hypothyroidism (Garber et al., 2012).
5. Colorectal Cancer
   • Justification: While less likely given the patient’s age and lack of alarming symptoms, it should be considered as a possibility.
   • Evidence: The American Cancer Society recommends considering colorectal cancer in adults with persistent changes in bowel habits, especially those over 45 years old (Wolf et al., 2018).

Primary Diagnosis: Functional Constipation

P. (Plan)

Pharmacological Interventions:

1. Osmotic Laxative: Polyethylene glycol (MiraLAX) 17g dissolved in 8 oz of water daily for 7 days
2. Stimulant Laxative: Bisacodyl 5mg orally at bedtime as needed for no bowel movement in 2 days

Non-Pharmacological Interventions:

1. Dietary modifications:

• Increase fiber intake to 25-30g daily (e.g., fruits, vegetables, whole grains)
• Increase water intake to at least 8 glasses (64 oz) daily
• Limit caffeine and alcohol intake

1. Exercise:

• Resume regular exercise routine, aiming for at least 30 minutes of moderate activity 5 days a week

1. Toileting habits:

• Establish a regular toileting schedule, especially after meals
• Do not ignore urges to have a bowel movement

1. Stress management:

• Practice relaxation techniques such as deep breathing or meditation
• Consider counseling or cognitive behavioral therapy if stress persists

Patient Education:

1. Explain the importance of lifestyle modifications in managing constipation
2. Provide a list of high-fiber foods and a guide for gradually increasing fiber intake
3. Discuss proper use of prescribed medications and potential side effects
4. Emphasize the importance of staying hydrated and maintaining physical activity

Follow-up:

1. Schedule a follow-up appointment in 2 weeks to assess response to treatment
2. Instruct patient to call or seek medical attention if symptoms worsen, or if they experience severe abdominal pain, rectal bleeding, or fever
3. If symptoms persist despite interventions, consider referral to gastroenterology for further evaluation

Monitoring:

1. Advise patient to keep a symptom diary, including frequency and consistency of bowel movements
2. Monitor for any side effects from medications
3. Reassess medication regimen, including calcium supplements, at follow-up appointment]

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References

1. Lacy, B. E., Mearin, F., Chang, L., Chey, W. D., Lembo, A. J., Simren, M., & Spiller, R. (2016). Bowel disorders. Gastroenterology, 150(6), 1393-1407.
2. Lacy, B. E., Pimentel, M., Brenner, D. M., Chey, W. D., Keefer, L. A., Long, M. D., & Moshiree, B. (2021). ACG clinical guideline: management of irritable bowel syndrome. American Journal of Gastroenterology, 116(1), 17-44.
3. Bharucha, A. E., Pemberton, J. H., & Locke III, G. R. (2013). American Gastroenterological Association technical review on constipation. Gastroenterology, 144(1), 218-238.
4. Garber, J. R., Cobin, R. H., Gharib, H., Hennessey, J. V., Klein, I., Mechanick, J. I., … & Woeber, K. A. (2012). Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Thyroid, 22(12), 1200-1235.
5. Wolf, A. M., Fontham, E. T., Church, T. R., Flowers, C. R., Guerra, C. E., LaMonte, S. J., … & Smith, R. A. (2018). Colorectal cancer screening for average‐risk adults: 2018 guideline update from the American Cancer Society. CA: a cancer journal for clinicians, 68(4), 250-281.