History
Identifying Data
Female, 23 years old.
Chief Complaint (CC)
Patient reports being constipated and having hard and lumpy stools, which are less frequent than before – 2-3 times a week. There is no blood visible, but the patient complains about having to strain during defecation.
History of Present Illness (HPI)
The symptoms started to appear 3 months ago and did not get much worse since that time. The frequency of defecation before constipation was average. The patient does not experience any pain in the abdomen or lower abdomen area. The defecation is not painful as well. The defecation is not frequent, and the patient feels uncomfortable during it. She reports having a feeling of incomplete emptying after defecation. The patient did not attempt to take any medications or laxatives and did not change her diet during the onset of the problem. She admits to drinking less water and having an unhealthy diet.
Past Medical History (PMH)
Medications, OTC, Supplements
The patient does not take any medications or supplements.
Allergies
NKDA and no known intolerances or food allergies.
Past Medical History
The patient has no known history of constipation problems, bowel problems, or related issues.
Past Surgical History
The patient has no history of major surgeries.
Family History (FH)
There is no family history connected to the present issue. Both parents do not have severe bowel problems, pelvic floor dysfunction, or colorectal cancer. Mother has a history of an eating disorder treated with therapy and diet planning.
Social History (SH)
The patient reports having a stressful routine and a very busy schedule due to studying and working part-time. She admits to having bad dieting habits and not exercising. She does not visit any counseling therapists or takes any medications to relieve stress. The patient denies smoking, drinking, or using illicit drugs. The patient is a student. She lives in the dormitory and does not always have full access to the bathroom. The patient often skips breakfast or lunch and forgets to drink water during the day. This stressful routine may put the patient’s health at risk.
Review of Systems (ROS)
- General: The patient is distressed. She experienced insignificant weight loss during the last six months due to having an inconsistent sleeping regime and a bad diet. The patient reports having lower energy levels due to stress. She admits to feeling frustrated and tired.
- Cardiovascular: The patient denies any palpitations, dyspnea, or edema. She has no chest pains.
- Respiratory: The patient denies having problems with breathing, asthma, or coughing.
- Skin: The patient complains about having dry skin. She connects dryness with dehydration and eating habits.
- Musculoskeletal: The patient does not report having any joint pain, swelling, cramping, stiffness, or muscle pain.
- Gastrointestinal: The patient denies any changes in urgency. She reports to having hard lumpy and round stool with no visible discoloration, pus, or blood. She denies having any unusual abdominal pain, or pain during defecation and urination. The need to strain during defecation appeared three months ago and is not followed by painful sensations.
- Neurologic: The patient admits to having headaches and feeling tired due to sleep deprivation. She denies having seizures, dizziness, and memory loss.
- Allergic: The patient denies any food or animal-related allergies or seasonal allergies.
- Psychiatric: The patient denies having depression, suicidal thoughts, or anxiety. However, she admits to having high levels of stress and an inconsistent sleeping schedule. The stressful feeling started to influence her sleep approximately ten months ago after she started to study more attentively and the levels of stress have only increased since then.
Physical Examination (PE)
Vital Signs
- Height: 5’4”
- Weight: 110 lb
- Temperature: 98.5 F
- Pulse: 76 BPM
- BP: 118/75
General Survey
The patient is a healthy-looking female with signs of distress and tiredness. She answers the questions logically and concisely. However, she seems to lack the energy to engage in a long conversation. Her speech is clear. The patient recalls information without significant complications.
Systems Examination
Cardiovascular: The patient’s heartbeat is normal. The rate and rhythm are regular. There are no murmurs, clicks, gallops, or rubs. There is no edema or clubbing.
Respiratory: The patient’s breathing is even and the lungs are clear, no obstructions present.
Skin: The patient’s skin is warm and dry. The dryness on some spots is not severe. There are no bruises, scaling, ulcers, or other injuries visible.
Abdominal: Bowel sounds are present in all four parts. The abdomen is non-tender, non-distended, and soft. There is no hepatosplenomegaly. No palpable masses or stool are present. The rectal opening has no anal fissures.
Diagnosis: Functional Constipation
The patient’s abdominal exam showed no symptoms signifying the presence of mechanical causes of constipation. Furthermore, the patient’s systems examination revealed no major signs of constipation being a symptom of physical conditions. According to Bickley (2012), some conditions may be found in the stool that contains blood, or in the feces that are discolored in any way. However, the patient reported having no blood in the stool and on the toilet paper after defecation.
Thus, many conditions may be excluded. The patient does not take any medications and does not have any known allergies. Thus, there is little to no possibility of her reacting to certain products. According to Dains, Baumann, and Scheibel (2016), the lack of abdominal symptoms and bowel disturbances eliminates the possibility of IBS.
The patient’s levels of stress are alarming and maybe the central issue that led to constipation. She admits to having poor dietary habits and forgetting to drink water. Thus, constipation may be the result of dehydration and lack of fiber in the diet (Bickley, 2016). Bharucha, Pemberton, and Locke (2013) write that stress is one of the risk factors for constipation development. Moreover, according to Fischbach and Dunning (2015), “psychological stress may be a major cause of altered bowel habits” (p. 293).
The patient is visibly distressed and malnourished. Furthermore, the history of eating disorders in her family is also significant to the diagnosis, as the patient and her mother may respond similarly to high levels of stress. Thus, it is possible to assume that the patient has functional constipation, caused by the patient’s low-fiber diet, dehydration, and emotional distress.
Diagnostic Study
To assess the patient’s condition, one should remember that it is necessary to eliminate diagnoses that require different types of treatment. One should advise a patient to perform a blood test along with other baseline tests to find more information about the possible lack of nutrients and evaluate the stool specimen. Bharucha, Dorn, Lembo, and Pressman (2013) write that baseline lab and a therapeutic trial of laxatives and fibers are necessary steps of most evaluations, including the assessment that is described above. The results of these tests will allow one to confirm the diagnosis and advise appropriate treatment.
References
Bharucha, A. E., Dorn, S. D., Lembo, A., & Pressman, A. (2013). American Gastroenterological Association medical position statement on constipation. Gastroenterology, 144(1), 211-217.
Bharucha, A. E., Pemberton, J. H., & Locke III, G. R. (2013). American Gastroenterological Association technical review on constipation. Gastroenterology, 144(1), 218-238.
Bickley, L. S. (2012). Bates’ guide to physical examination and history-taking (11th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Bickley, L. S. (2016). Bates’ pocket guide to physical examination and history taking (8th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
Dains, J., Baumann, L., & Scheibel, P. (2016). Advanced health assessment and clinical diagnosis in primary care (5th ed.). St. Louis, MS: Elsevier Mosby.
Fischbach, F. T., & Dunning, M. B. (2015). A manual of laboratory and diagnostic tests (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.