Constipation due to Co-codamol

Casebank History
1

Where you are:
You are working as a Foundation year two doctor in the orthopaedic and trauma department.

Who the patient is:
Emma Watson, a 70-year-old female has been admitted to the hospital.

Other information you have about the patient:
Patient had hemiarthroplasty 4 days ago because of fracture of the neck of femur.
She hasn’t passed any stool since she was admitted.
Patient is taking co-codamol for pain.
Her pain is controlled now and she is stable.

What you must do:
Please talk to the patient, take history, assess the patient condition, perform any relevant examination, discuss plan of management with the patient.

Patient Information

  • You are a 70 year old female, Emma Watson.
  • You had a fall 1 week ago.
  • You were admitted 1 week ago for a hip surgery and had an operation 4 days ago.
  • You had no constipation before admission.
  • You have not been able to open your bowels for 7 days.
  • You are taking co-codamol.
  • The last time you opened your bowels was before you broke your femur bone.
  • Before the fracture, you used to open your bowels every day.
  • You were fully mobile before you had a fall
  • You are able to pass wind
  • You have no abdominal pain.
  • You eat a lot of fibre in your diet and drinks a lot of fluid.
  • You slipped on the toilet and broke your femur
  • The operation went well
  • Your pain is well controlled
  • You are normally fit and well
  • No past medical history
  • no allergies
  • no medications

Questions

  • What are you going to do for me doctor?
  • if you stop this medication, will i not be in pain again? (ask this question only if the doctor suggests to stop the medication)
  • What is a phosphate enema?
  • What are laxatives?
  • “ I am amazed how you guys are dressing. I was in so much pain and now i am completely fine.”

Examiners Prompt:
If the candidate mentions he wants to perform abdominal examination give findings verbally.

Abdominal Examination: There is a mass in the left iliac fossa.
Per Rectal Examination : Loaded with faecal impaction

Observation charts should have the following vitals and should be given to the cadidate who mentions observations.

Temperature: 37C
BP: 120/80 mmHg
HR 80 bpm

Data Gathering

GRIPS, and paraphrase

  • How is your recovery going?
  • Have you been seen by the occupation and physiotherapists yet?

History

  • ODPARA of constipation
  • Rule out intestinal obstruction
  • Rule out D/Ds
  • MAFTOSA

Examination

  • Observations: T, HR, Blood pressure, RR,O2
  • Abdominal Pain, vomiting (rule our intestinal obstruction), passing gas or not?
  • Abdominal examination
  • PR examination-hard stools

Management

Explain reason for constipation:

  • Co-codamol
  • Decreased Mobility

Investigation

  • Blood test LFTs, FBC, U and E
  • abdominal X-ray.

Explain your findings and diagnosis.

  • Constipation is due to medication called cocodamol. This medicine has paracetamol and codeine. Cocodamol cause constipation.
  • Ask patient about mobility
  • Only give paracetamol and if needed ibuprofen can be given.
  • Continue follow up with physiotherapy.
  • High fibre diet.
  • Take a lot of fluid.
  • Also can give phosphate enema. Which is a strong laxative which helps to soften the stool.
  • Offer ibuprofen, but only ask for indigestion first.
  • Also can give laxatives to help in the defecation. ( luctolose)

Literature

2

Post op constipation

History

  • You are FY2 in orthopaedic department.
  • A 79 year old woman has been admitted to the hospital. She had a hemi-arthroplasty 4 days back because of fracture in the neck of femur.
  • She has not passed any stools since she was admitted.
  • She is on co-codamol for pain. Pain Is well controlled and she is stable.
  • She had no constipation before admission. Has been unable to empty her bowel for 7days now. Before fracture she used to open bowel daily.
  • She was also fully mobile before the fall.
  • She is not on any medication and can pass wind.
  • She takes a lot of fluids and fiber.
  • No previous history of allergies and no significant medical history.
  • She wants to go home , lives alone no ones thereby

Task:

  • Please talk to her and discuss management
  • Examination and investigation:
  • Take observations , abdomen and back passageExamine wound site

Management:

  • Greet and confirm identity
  • build rapport
  • Ask about operation,
  • any complications, pain , symptoms,
  • about hospital stay and care

Data Gathering

  • Explore Constipation,
  • ODPARA,
  • rest of GIT symptoms such as tummy pain, diarrhea, vomiting, fever,
  • nausea,
  • Differentials
  • DESA,
  • MAFTOSA,
  • Ask concern , idea
  • Verbalise examination and summarise,
  • explain the pain killer you are taking could be the cause of your constipation
  • open BNF and show her

Management

  • Reassure and Advice
  • Take fruits and vegetables as they are enriched with fibers , take Plenty of fluids
  • Advice Mobilization, Stop the co-codamol and assess the pain to
  • prescribe another one like paracetamol
  • Offer Laxatives
  • involve multidisciplinary team , physiotherapist to star appropriate mobility and occupational therapist to assess her living situation and make adjustments.
  • Offer if she needs any carer
  • Safety netting
3

Station Details

  • Role: FY2 in Orthopaedic Department.
  • Patient: Kate, a 70-year-old woman admitted to the hospital.
    • Background: Hemi-arthroplasty 7 days ago due to a fracture in the neck of femur.
    • Current Issue: Has not passed stools since admission, on co-codamol for pain, which is well controlled.
    • History: No prior constipation, daily bowel movements before the fracture, fully mobile before the fall, not on any other medication, can pass wind, takes a lot of fluids and fiber, no history of allergies or significant medical history.
    • Living Situation: Lives alone and wishes to go home.

Task: Discuss management of constipation with Kate.

Examination and Investigations:

  • General Physical Examination (GPE)
  • Vitals
  • Examine wound

Approach:

  1. Greet, Introduce, and Confirm Identity: Build rapport.
  2. Questioning: Ask about the operation, complications, pain, symptoms, hospital stay, and care.
  3. Explore Constipation:○ ODPARA
    • Gastrointestinal (GIT) symptoms such as tummy pain, diarrhea, vomiting, fever, nausea.
    • Rule out differential diagnoses (D/Ds)
    • DESA
    • MAFTOSA
    • Investigate Ideas, Concerns, and Expectations (ICE)
  4. Explanation and Management:
    • Explain that co-codamol prescribed for pain may cause constipation.
    • Reassure and advise:
      • Increase intake of fruits and vegetables for fiber.
      • Drink plenty of fluids.
      • Mobilize as much as possible.
      • Stop co-codamol and assess pain to prescribe alternatives like paracetamol.
      • Offer laxatives and involve the multidisciplinary team:
      • Physiotherapist for mobility.
      • Occupational therapist for assessing living situation and making adjustments.
      • Offer assistance if needed.
      • Provide safety netting.