Gastrointestinal Function
R.H. is a 74-year-old black woman, who presents to the family practice clinic for a scheduled appointment. She complains of feeling bloated and constipated for the past month, some-times going an entire week with only one bowel movement. Until this episode, she has been very regular all of her life, having a bowel movement every day or every other day. She reports straining most of the time and it often takes her 10 minutes at a minimum to initiate a bowel movement. Stools have been extremely hard. She denies pain during straining. A recent colonoscopy was negative for tumors or other lesions. She has not yet taken any medications to provide relief for her constipation. Furthermore, she reports frequent heartburn (3–4 times each week), most often occur-ring soon after retiring to bed. She uses three pillows to keep herself in a more upright position during sleep. On a friend’s advice, she purchased a package of over-the-counter aluminum hydroxide tablets to help relieve the heartburn. She has had some improvement since she began taking the medicine. She reports using naproxen as needed for arthritic pain her hands and knees. She states that her hands and knees are extremely stiff when she rises in the morning. Because her arthritis has been getting worse, she has stopped taking her daily walks and now gets very little exercise.
Case Study Questions
In your own words define constipation and name the risk factors that might lead to develop constipation. List recommendations you would give to a patient who is suffering from constipation. You might use a previous experience you might have.
Based on the clinical manifestations on R.H. case study, name and explain signs and symptoms presented that are compatible with the constipation diagnosis. Complement your list with signs and symptoms not present on the case study.
Sometimes as an associate diagnosis and a complication, patients with constipation could have anemia. Would you consider that possibility based on the information provided on the case study?
Endocrine Function:
C.B. is a significantly overweight, 48-year-old woman from the Winnebago Indian tribe who had high blood sugar and cholesterol levels three years ago but did not follow up with a clinical diagnostic work-up. She had participated in the state’s annual health screening program and noticed that her fasting blood sugar was 141 and her cholesterol was 225. However, she felt “perfectly fine at the time” and could not afford any more medications. Except for a number of “female infections,” she has felt fine until recently. Today, she presents to the Indian Hospital general practitioner complaining that her left foot has been weak and numb for nearly three weeks and that the foot is difficult to flex. She denies any other weakness or numbness at this time. However, she reports that she has been very thirsty lately and gets up more often at night to urinate. She has attributed these symptoms to the extremely warm weather and drinking more water to keep hydrated. She has gained a total of 65 pounds since her last pregnancy 14 years ago, 15 pounds in the last 6 months alone.
Case Study Questions
In which race and ethnic groups is DM more prevalent? Based on C.B. clinical manifestations, please compile the signs and symptoms that she is exhibiting that are compatible with the Diabetes Mellitus Type 2 diagnosis.
If C.B. develop a bacterial pneumonia on her right lower lobe, how would you expect her Glycemia values to be? Explain and support your answer.
What would be the best initial therapy non-pharmacologic and pharmacologic to be recommended to C.B?
- Medications: Certain medications can cause constipation as a side effect (e.g., opioids, some antacids, certain antidepressants, iron supplements).
- Medical Conditions: Various medical conditions can contribute to constipation (e.g., irritable bowel syndrome (IBS), hypothyroidism, neurological disorders, colorectal cancer).
- Changes in Routine: Travel, changes in diet, or daily schedule disruptions can affect bowel habits.
- Psychological Factors: Stress, anxiety, and depression can sometimes contribute to constipation.
Recommendations for Constipation Relief:
Based on my experience, I would recommend the following to a patient suffering from constipation:
- Dietary Modifications:
- Increase Fiber Intake: Gradually increase the consumption of high-fiber foods such as fruits (especially with skin), vegetables, whole grains (oats, bran, whole wheat), and legumes. Aim for 25-30 grams of fiber per day.
- Adequate Fluid Intake: Drink plenty of water throughout the day. Aim for at least 8 glasses of water or other non-caffeinated, non-alcoholic beverages daily.
- Lifestyle Changes:
- Regular Exercise: Engage in regular physical activity, even moderate exercise like walking, can help stimulate bowel function.
- Establish a Regular Bowel Routine: Try to have bowel movements at the same time each day, preferably after a meal when the urge is often strongest.
- Do Not Ignore the Urge: Respond to the urge to defecate promptly. Ignoring it can make stools harder and more difficult to pass.
- Proper Toilet Posture: Elevating the feet slightly with a stool can help to align the colon and rectum for easier passage of stool.
- Over-the-Counter (OTC) Remedies (with caution and guidance):
- Bulk-forming laxatives (e.g., psyllium, methylcellulose): These absorb water in the gut, increasing stool bulk and making it easier to pass. They are generally considered safe for long-term use but should be taken with plenty of water.
- Stool softeners (e.g., docusate): These help to moisten the stool, making it softer and easier to pass.
- Osmotic laxatives (e.g., polyethylene glycol, lactulose): These draw water into the bowel, softening the stool and increasing bowel movements.
- Stimulant laxatives (e.g., senna, bisacodyl): These stimulate the muscles of the colon to contract. They should be used sparingly and not for long-term management unless directed by a healthcare provider, as they can lead to dependence.
- Prescription Medications (if OTC remedies are insufficient and under medical guidance): There are prescription medications available for chronic constipation.
- Review Medications: Discuss all current medications with a healthcare provider to identify if any are contributing to constipation.
- Stress Management: Practice stress-reducing techniques if stress is a contributing factor.
- Follow-up with a Healthcare Provider: If constipation persists despite lifestyle and dietary changes or if there are concerning symptoms (e.g., rectal bleeding, severe abdominal pain, unintentional weight loss), it's important to seek medical evaluation.
Signs and Symptoms of Constipation in R.H.'s Case:
Present in the Case Study:
- Feeling bloated: This is a common symptom of retained stool and gas in the intestines.
- Constipation for the past month: A change in bowel habits to less frequent movements is a key indicator of constipation.
- Sometimes going an entire week with only one bowel movement: This significantly deviates from her lifelong regularity.
- Straining most of the time: Difficulty passing stool and the need to exert significant effort are characteristic of constipation.
- It often takes her 10 minutes at a minimum to initiate a bowel movement: This indicates difficulty in the process of defecation.
- Stools have been extremely hard: Hard stools are a direct result of slower transit time in the colon, leading to increased water absorption.
- Negative colonoscopy for tumors or other lesions: While this rules out some serious causes of constipation, it doesn't exclude functional constipation or other contributing factors.
- Has not yet taken any medications to provide relief for her constipation: This indicates the problem is recent enough that she hasn't sought treatment.
Signs and Symptoms Not Present in the Case Study (but often associated with constipation):
- Abdominal pain or cramping: While R.H. denies pain during straining, she may experience general abdominal discomfort or cramps related to constipation.
- Feeling of incomplete evacuation: The sensation that the bowels are not fully emptied after a bowel movement.
- Rectal bleeding or pain during defecation: This can occur due to hard stools causing fissures or hemorrhoids.
- Nausea or decreased appetite: Severe or prolonged constipation can sometimes lead to these symptoms.
- Headaches: Some individuals report headaches associated with constipation.
Possibility of Anemia as an Associate Diagnosis or Complication:
Based on the information provided in the case study, it is less likely that R.H.'s constipation is currently causing anemia. Here's why:
- Denies pain during straining: Significant rectal bleeding from hemorrhoids or fissures, which can be a complication of chronic constipation, is a potential cause of anemia. Her denial of pain during straining makes this less likely.
- No mention of other symptoms of anemia: The case study does not report symptoms such as fatigue, weakness, shortness of breath, or pale skin, which are common indicators of anemia.
However, it's important to consider that:
- Chronic, low-grade bleeding: It is possible to have chronic, low-level bleeding from hemorrhoids or fissures that the patient might not be aware of or might not consider significant pain, which could contribute to iron deficiency anemia over time.
- Nutritional factors: Older adults, particularly those with dietary changes or malabsorption issues, can be at risk for nutritional deficiencies (e.g., iron, vitamin B12, folate) that can cause anemia, and these factors could potentially coexist with constipation.
Therefore, while anemia is not strongly suggested by the current information, it would be prudent to consider it, especially if her constipation becomes chronic or if she develops other symptoms suggestive of anemia. Further investigation, such as a complete blood count (CBC), could be warranted if clinically indicated.
C.B.'s Case Study: Endocrine Function (Diabetes Mellitus Type 2)
Race and Ethnic Groups with Higher Prevalence of DM:
Diabetes Mellitus (DM) is more prevalent in certain racial and ethnic groups in the United States compared to non-Hispanic White individuals. These groups include:
- American Indians and Alaska Natives: This group has the highest rates of diabetes in the U.S.
- Non-Hispanic Blacks: African Americans have a significantly higher prevalence of diabetes.
- Hispanics/Latinos: This group also experiences a higher rate of diabetes.
- Asian Americans: While often grouped together, certain subgroups of Asian Americans (e.g., South Asians, Filipinos) have a higher risk.
- Pacific Islanders: This group also has a higher prevalence of diabetes.
Based on C.B.'s clinical manifestations, the signs and symptoms compatible with the Diabetes Mellitus Type 2 diagnosis are:
- History of high blood sugar three years ago (fasting blood sugar 141 mg/dL): This is a significant risk factor and a potential early indicator of prediabetes or undiagnosed diabetes. A fasting blood sugar of 126 mg/dL or higher on two separate occasions is diagnostic for diabetes.
- Weak and numb left foot for nearly three weeks, difficult to flex: This is highly suggestive of peripheral neuropathy, a common complication of chronic hyperglycemia damaging the nerves, often starting in the feet and legs.
R.H.'s Case Study: Constipation
Definition of Constipation:
Constipation is generally defined as infrequent bowel movements, difficult passage of stools, or a feeling of incomplete evacuation. The frequency of bowel movements varies greatly among individuals, but often constipation is characterized by having fewer than three bowel movements per week.
Risk Factors for Constipation:
Several factors can contribute to the development of constipation, including:
- Dietary Factors: Low fiber intake (fruits, vegetables, whole grains), inadequate fluid intake.
- Lifestyle Factors: Lack of physical activity, sedentary lifestyle, ignoring the urge to defecate.
- Age: Constipation is more common in older adults due to slower metabolism, reduced physical activity, and other medical conditions.