Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Year 2 Doctor working in an emergency department. Your next patient is an 18-year-old female (Susan Williams) presenting with constipation. Please take a history and perform an appropriate examination.
Patient History:
Susan Williams, 18-year-old Year 1 Medical Student
You developed constipation in the last 2 days. When you go to the toilet, the stools are small and pellet-like (no blood or mucus). You found it strange as you also had diarrhoea 1 week ago; it was more watery/ loose.
You are unsure if you have eaten anything weird in the past few days. However, you know you have not been eating and drinking as much and generally have a poor appetite due to exam stresses. You have lost around 2-3 kg in the past few weeks because of this.
You also have some aching 3/10 abdominal pain around the lower left side of your tummy. It comes and goes. Worsened by eating and relieved by pooping / passing wind.
Every time you go to the toilet, you do not feel fully emptying your bowel. You always feel an urge to go to the toilet quickly after just opening your bowels. You have been going to the toilet 2-3 times a day.
You noticed that your tummy had gotten a little bloated, which happens occasionally.
You have been feeling quite tired lately, and as a result, this has impacted your focus during your studies. You have been taking regular naps after lectures. You are stressing out as you have an exam coming up, and you need more time to revise. You think you are going to fail!
No urinary symptoms. Not sexually active. No fever. No weight loss. No vomiting or nausea. No headache. No Belching. No tiredness. No heartburn.
Ideas, Concerns, Expectations:
You think constipation is related to stress because you are really worried about your exam since it counts for more than 50% of the total mark for the year, and you want to do well. You want to seek some medications to help with constipation.
Past Medical History:
Asthma
Drug History:
Salbutamol PRN 100microgram
NKDA
Family History:
Colonic Cancer in father diagnosed at age 65
Social History:
Medical student.
Don’t smoke.
Drink occasionally with friends.
No recreational drugs.
Examination Findings:
Generalised discomfort on abdominal palpation – worse at palpating lower left quadrant. No guarding. Bowel sound present.
Might involve PR examination to exclude other diagnoses – check for impacted stools + blood. PR shows constipation, otherwise normal.
Differentials:
Irritable Bowel Syndrome
Dehydration
Anxiety
Diverticular Disease
IBD/ Coeliac Disease
Investigations:
Bedside:
Set of observations
Faecal calprotectin
Faecal occult blood
Urine dipstick
Blood Test:
Routine including FBC, CRP/ESR, TFT, U&E, LFTs, Bone Profile
Coeliac disease screen (Anti-TTG antibodies)
Consider pregnancy test
Imaging/Special Test:
Consider AXR or further imaging
Consider endoscopy if the diagnosis is uncertain
Management: