CCS Interactive Case 20

Question 1

62 y/o M, hx DMII, HTN, HLD presents w/6 weeks constipation. +Abdominal distention after meals, diet primarily red meat. Medications are metformin, glipizide, lisinopril, ASA, simvastatin.

HDS, no weight loss, change in stool caliber, last colonoscopy 12 years ago

DDx?

Answer 1

Inadequate fiber/fluid intake
Medication side-effect
Colonic obstruction by tumor
Diabetic autonomic neuropathy
Hypothyroidism

Question 2

Exam steps?

Answer 2

Complete physical

Question 3

Distended and tympanic abdomen, rectal vault containing hard stool

Next step?

Answer 3

CBC
FOBT
BMP
Mg
Phos
TSH
A1C
Microalbumin
Colonoscopy

Question 4

Slightly elevated A1C, results otherwise WNL

Management?

Answer 4

Initial treatment: patient education (increased fluid and fiber intake), bulk forming laxatives (psyllium, methylcellulose) and/or milk of mag, avoid constipting medications (narcotics, CCBs, anticholinergics)

If no response - consider other classes of laxatives (docusate, lactulose, sorbitol, mag citrate, senna, bisacodyl)
Disimpact if impaction
Consider further studies (colonic transit studies, anorectal manometry, pelvic floor studies)

Question 5

Sequence?

Answer 5

Exam (complete)
Order: CBC w/diff, BMP, Mg, Ph, TSH, A1C, FOBT, colonoscopy (all routine)
Rx metamucil (psyllium), oral, continuous
High fiber diet, low salt, low fat, exercise, oral hydration
Counseling
Location - home
Schedule appt in 1 week
Symptoms improve, case ends
Final orders - none
Dx - chronic constipation