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M.C. a 46-year-old hispanic female presents to the GI-Motility clinic for complaint of chronic constipation, incomplete defecation and abdominal bloating. She has pmhx of DM-type 2, IBS-Constipation, Tubular Adenoma.

Week 7: DISCUSSION QUESTION IN DISCUSSION BOARD

Gastroenterology-Motility Case Study

ACC/AHA Guidelines

Chief complaint: “ I have chronic constipation, incomplete defecation and abdominal bloating” for past 2 years.

HPI: M.C. a 46-year-old hispanic female presents to the GI-Motility clinic for complaint of chronic constipation, incomplete defecation and abdominal bloating. She has pmhx of DM-type 2, IBS-Constipation, Tubular Adenoma.

She also indicates that she has noticed that her symptoms are worsening for past 3 months. She has associated her symptoms with abdominal bloating, straining and incomplete defecation.

She has tried Miralax one packet po daily for at least 8 weeks and it has not relieved her symptoms.

Denies associated symptoms of hematochezia, melena, hemoptysis, abdominal pain, fever, chills, pain or any other symptoms.

PMH:

Diabetes Mellitus, type 2

Constipation, chronic-IBS

Surgeries: None

Allergies: Penicillin

Vaccination History:

She receives an annual flu shot. Last flu shot was this year

Social history:

High school graduate, married and no children. He drinks one 4-ounce glass of red wine daily. He is a former smoker that stopped 3 years ago.

Family history:

Both parents are alive. Father has history of DM type 2, Tinea Pedis.

mother alive and has history of atopic dermatitis, tinea corporis and tinea pedis.

ROS:

Constitutional: Negative for fever. Negative for chills.

Respiratory: No Shortness of breath. No Orthopnea

Cardiovascular: + 1 pitting leg edema. + Varicose veins.

Skin: + rash crusted white in feet and inter-digit in feet.

Psychiatric: No anxiety. No depression.

Physical examination:

Vital Signs

Height: 5 feet 5 inches Weight: 140 pounds BMI: 31 obesity, BP 110/70 T 98.0 po P 80 R 22, non-labored

HEENT: Normocephalic/Atraumatic, PERRL, EOMI; No teeth loss seen. Gums no redness.

NECK: Neck supple, no palpable masses, no lymphadenopathy, no thyroid enlargement.

LUNGS: Lungs clear bilaterally. Equal breath sounds. Symmetrical respiration. No respiratory distress.

HEART: Normal S1 with S2 during expiration. Pulses are 2+ in upper extremities. No edema.

ABDOMEN: No abdominal distention. Nontender. Bowel sounds + x 4 quadrants. No organomegaly. Normal contour; No palpable masses.

GENITOURINARY: No CVA tenderness bilaterally. GU exam deferred.

MUSCULOSKELETAL: Slow gait but steady. No Kyphosis.

SKIN: +Dryness, No open lesions. +Dry crusts in sole of feet. + moist crust in between toes.

PSYCH: Normal affect. Cooperative.

Labs day of visit:: Hgb 15.2, Hct 40%, K+ 4.0, Na+137, Serum Creatinine normal 1.0, AST/ALT normal. TSH 3.7 normal, glucose 98 normal

A:

Primary Diagnosis: Chronic Constipation, ideopathic

Secondary Diagnoses:

Incomplete Defecation

IBS-Constipation

Differential Diagnosis:

Small intestine bacterial overgrowth (SIBO)

Plan: Medications:

Miralax one packet po daily for at least 8 weeks.

Plan: Tests

Anorectal Manometry with rectal sensation/tone compliance test to evaluate if patient has dyssynergic defecation. If test positive then will consider ordering sessions of Biofeedback bowel retraining program to correct cause of incomplete defecation.

Labs: No new labs are needed.

Referrals: may refer based on effect of medication therapy given for 2 weeks.

Follow up: return to office in 8 weeks to reevaluate her symptoms.

Questions: As an NP student, needs to determine the medications for constipation.

According to the ACC/AHA Guidelines, what medication should this patient be prescribed for constipation? Write her complete prescriptions using the prescription writing format.

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