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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Identify the causes of constipation

  • Recognize the symptoms of functional constipation

  • Identify the goals of therapy for functional constipation

  • Recommend lifestyle modifications and therapeutic interventions for the treatment of functional constipation

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PATIENT PRESENTATION

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Chief Complaint

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"I'm constipated. I haven't had a bowel movement in 4 days, and this isn't the first time it has happened."

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History of Present Illness

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Quoba Nestor is a 48-year-old female who presents to her physician's office complaining of constipation. QN is evaluated every 6 months by her primary-care physician and was last seen 5 months prior to presentation. Upon further questioning by her physician, QN reported that she often has to strain when attempting to have a bowel movement. When she does have a movement, her stools are small, dry, and hard. She had used docusate in the past with some benefit, but recently it seemed to stop working. She has tried psyllium in the past, but she didn't like mixing it with so much water and it made her constipation worse. QN denied abdominal pain. QN has a history of HTN and neuropathic, joint, and muscle pain.

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Past Medical History

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Essential HTN

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Neuropathic pain—radiculopathy caused by traumatic injury

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Family History

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Father is alive at age 72 and has CAD, HTN, osteoarthritis, and type 2 DM. Mother is alive at age 67 with type 2 DM, HTN, osteoarthritis, and hypercholesterolemia. QN has three siblings; all are living. Two siblings are known to have migraine headaches and HTN, and one sibling has type 1 DM.

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Social History

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QN is a divorced mother of two children aged 19 and 15. She works as a paralegal for the county government.

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Tobacco/Alcohol/Substance Use

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(−) Alcohol, tobacco, or illicit drug use

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Allergies/Intolerances/Adverse Drug Events (ADEs)

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Gabapentin (pruritus)

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Medications (current)

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Lisinopril 40 mg PO q day

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HCTZ 25 mg PO q day

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Amitriptyline 50 mg PO at bedtime

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Multivitamin 1 tablet PO every 24 hours

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Ibuprofen 200 mg PO every 8 hours as needed for headaches and joint and muscle pain

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Review of Systems

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Occasional headaches and joint and muscle aches and pains are relieved with ibuprofen; noticed a change in bowel habits when she started taking amitriptyline for neuropathic pain caused by traumatic injury; feels full

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Physical Examination

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General
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Well-developed, well-nourished middle-aged female in no acute distress

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Vital Signs
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BP 120/80 mm Hg, P 70, RR 20, ...

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