Constipation due to Dihydrocodeine

Casebank History
1

Where are you?
FY2 in Orthopaedics and trauma department

Who the patient is:
A nurse is concerned about one of her patients and she would like to speak to you. This is your first day in this department

Other information you have about the patient:
None

What you must do:
Talk to the nurse about the patient

You are a nurse who is concerned about one of your patients.

Patient Information:

  • Patient name is Joana James. (Female)
  • Age: 75 years old.
  • Admission date: 2 weeks ago
  • Reason for admission: Fall down at home and sustained a fracture of her left arm

Current problems:

  • Not opening the bowels for the past 5 days.
  • Patient is not mobilizing.
  • Sustained a T2 Fracture when she fell down but is being treated conservatively.
  • Patient is confused as well.
  • Patient had diarrhoea for 3 days before developing constipation.
  • You don’t know about her diet.

PMH: Nil
Drug history: Patient is taking dihydrocodeine for the neck pain.
Allergies: Nil

On Examination:

  • Observations: HR: 98 - BP: 120/80 - RR: 14 – O2 sat 98% on room air
  • Abdominal examination: normal
  • Per rectal examination: Normal (No blood - No faecal Impaction - No perianal paresthesia)

Questions:

  • So what are we going to do?
  • What is the cause of the constipation?

GRIPS

  • Use the word ‘’we’’
  • Talk like a colleague
  • Introduce yourself by first name
  • How are you doing?
  • Is everything going good with you in this department?
  • I understand that you have a got a patient that you would like to discuss with me. Can you tell me what’s wrong with the patient?

HISTORY TAKING (Focused History)
Presenting Complaint

History of admission, do we know…

  • What was the reason for her admission?
  • What has been done so far?
  • How is she being managed?

ODPARA (for Constipation)

Differential Diagnosis

  • Immobility Do we know if…
    • She is able to move freely and keep mobile?
  • Medications Do we know if…
    • She is taking any medication for pain relief?
    • She is taking any other medication?
  • Dietary
    • Do we know about her diet? Does she eat enough fruits and vegetables?
    • Does she drink enough water?

Red flags

  • Intestinal obstruction Do we know if…
    • She has any abdominal pain?
    • She has any vomiting or diarrhoea?
    • She passes gas?
    • She has any abdominal distention?
  • Spinal cord compression Do we know if
    • She has any urinary problems?
    • She has any weakness or sensory loss in her legs?

PMAFTOSA: Do we know about her past medical history?

ICE
I – Ideas: Is there anything you feel could be the cause of her symptoms?
C – Concerns: Is there anything else you are concerned about?
E – Expectation: at the end of consultation

Summarize

  • Let me go through everything you have told me so far, to make sure I have understood
    correctly. So, you have told me that … You mentioned that … You also mentioned that … Is there anything i missed?

EXAMINATION

Observations
Do we have her vitals? Is the patient stable?
BP – Pulse – Oxygen – RR – Temp

Specific Examinations

  • Have you had any chance to examine the patient?
  • Abdominal examination Is there anything on abdominal examination?
  • Per rectal examination Is there anything on per rectal examination?

PROVISIONAL DIAGNOSIS

  • From what you have told me so far, it seems that she has got constipation secondary to
    dihydrocodeine. And I think what we need to do next is to rule out anything else. So I will just
    review the patient in terms of abdominal and per rectal examination, and may be to do a
    neurological examination of her lower limbs to make sure everything is normal.

MANAGEMENT

  • Routine investigations
  • Then we need to run some blood tests such as FBC – U&E – LFT – Blood sugar – TFT to
    make sure there is nothing else going on like electrolyte imbalance, a urine dipstick to rule
    out UTI as a cause of confusion, and we also need to do an abdominal x-ray to rule out intestinal obstruction.

Treatment/Decision

  • I suggest that we stop the dihydrocodeine, and change it to Paracetamol as required
  • and if needed; ibuprofen can be given as well.
  • Also we can give her some laxative, such as Senna.
  • And advise her to take high fibre diet and drink a lot of fluid.
  • It is also important to invite the physiotherapist to review and start appropriate mobility, as mobility will enhance the bowel movements.

Summarize: Let us recap what we have discussed…

Expectations

  • Do you have any other concerns?
  • Do you have any suggestions?