Constipation


Case Study

1. Explain the primary pathophysiology of constipation.

• Constipation is challenging to define because bowel habits are unique to each individual just as another physiological process. For example, a young active person may have several bowel movements a day while a less active elderly person may only defecate once a week. Decreased frequency of defecation becomes a more significant issue is when it impacts the quality of life and health of a patient (McCance & Huether, 2014).  Intrinsic causes of constipation can be due to structural changes like sphincter dysfunction or decreased peristalsis. In many cases it is secondary to other pathological states. It has been reported that up to 28% percent of Americans are affected by constipation (Andrews & Storr, 2011). Constipation can be categorized into 3 different types. Functional constipation, which is related to diet, hydration and level activity. Slow-transit constipation is caused by decreased motility in gastrointestinal track. Pelvic floor dysfunction is associated with the inability to control the muscles of the anal sphincter.
• As mentioned above, constipation can be secondary other diseases or even medications. Both neurological and endocrine pathologies can impact one’s ability to have healthy bowel habits. Opioids, anticholinergics, antacids and antidepressant can all impair the ability to defecate (McCance & Huether, 2014).  An important take away for this is when a patient presents to the clinic with something as “simple” as constipation it would be important to ensure a comprehensive evaluation of the patient.

2. Differential Diagnosis:

Differential Dx:	Pertinent Positives	Pertinent Negatives
Small Bowel Obstruction secondary to GI malignancy (Colorectal Cancer)	-Weight loss of 30 lbs over last 3 months. – On assessment there was a lump palpated in patients’ rectal cavity. – “Fullness in LLQ” upon assessment of ABD.	-Patient ABD is non-tender upon palpation. No report of abdominal cramping. -Does not report recent increase incidence of vomiting. -Patient can have a bowel movement but requires taking a laxative.
BPH/Adenocarcinoma of the prostate	– On assessment there was a lump palpated in patients’ rectal cavity. – Patient is male and of advanced age, 75 years old. – Active smoker, 2 packs per day for 60 years (80 pack-year history) -Positive for HTN.	– Patient denies dysuria. – Does not report urinary urgency. – No known family history of cancer. -Patient does not has increased body fat with BMI of 19.
Anal Fistula	-Patient has good anal sphincter tone but there is a hemorrhoids present form straining. -Occult blood test of stool was positive.	– No reports of rectal pain or infectious drainage. – No reports of prior anal fistulas or abscesses.

3. 
   Leading Diagnosis:
   
   After reading the assessment of Mr. H the most likely etiology of his constipation is a small bowel obstruction (SBO) secondary to an active, more serious disease process. Mr. H has several risk factors for cancer including his 80 pack-year history, chronic hypertension, gender and age. The two most significant assessment findings is the fullness in the LLQ and the palpable mass on his rectal cavity.

4. I would like the obtain a more thorough assessment of the following systems:

• 
  General Survey:
  
  Patient’s BMI is 19 which is considered to be a normal weight but on the lower end of the range. If he continues to lose weight, he is at risk to become malnourished. I would also like to know more about the current medications the patient is taking, if any.
• 
  Abdominal Assessment:
  
  McBurney’s test would not be helpful in this instance due to the fact the patient has had his appendix removed. Deeper palpation would be helpful in identifying the fullness in LLQ. An CT ABD would also be helpful in diagnosing a SBO. Would inquire of a history of abnormal colonoscopy findings.
• 
  Urogenital Assessment:
  
  I would like to inquire more about the patient’s urinary habits patterns. He denies dysuria but would ask if he has trouble starting a stream of urine or if he experiences urinary frequency. I would ask the patient if he experiences erectile dysfunction.
• 
  Prostate and Anal Assessment:
  
  I would like to know more about this mass in rectal cavity. A prostate specific antigen (PSA) is indicated in this case with a possible prostate biopsy.
• 
  Cardiovascular Assessment:
  
  Patient current vital signs are stable with BP of 110/75 and HR: 100 BPM but I would like to know what the trends of the BP and HR are. If the patient has a history of HTN and CAD, does he take medications that control his BP.
• 
  Pulmonary Assessment:
  
  Considering the patients hx of smoking I would like to do a thorough assessment of pulmonary function. He has an increased AP diameter and chronic COPD. A chest X-ray would be indicated. I would also like to know the FEV1/FVC ratio is seeing that this patient has COPD.
• 
  Musculoskeletal Assessment:
  
  I would ask if the patient has any mobility restrictions, especially when transitioning from sitting to standing positions.
• 
  Family History:
  
  Although patient cannot remember how parents died I would like to know more about the presence of cancer his is family.
• 
  Endocrine Assessment:
  
  Although unlikely would assess for DMII by obtaining a A1C.

Mental Status Changes Case Study

1. Explain the Pathophysiology of Increased Confusion:

2. Differential Diagnosis:

Differential Dx:	Pertinent Positives	Pertinent Negatives
Chronic Traumatic Encephalopathy
Dehydration secondary to sepsis or infectious process	-Staff at care facility reports decreased appetite and NVD over past 3 days -Poor skin turgor and dry oral mucosa on exam -Hypotension (90/60) and tachycardia (120 BPM) -Mental status changes were acute onset	-Patient has been afebrile -Peripheral pulses 2+, lower extremities are “supple”
Cerebral Vascular Accident (CVA)	-Patient has a hx of several lacunar strokes -Patient has HTN and DMII, not on insulin therapy – Mental status changes were acute onset, normally patient is pleasant and redirectable -Patient is unable to disoriented and unable to perform rapid alternating movement tasks in neuro exam.	-CN II-XII are intact -Pupils are equal and reactive to light consensually -No unilateral deficits noted

3. 
   Leading Diagnosis:
   
   At this, it is evident that dehydration is the most likely cause of this acute onset of confusion. Patient is hypotensive (normally hypertensive), tachycardic, has poor skin turgor, dry mucous membranes and has had multiple episodes of NV at care facility. Whether there is an infectious process causing these symptoms would be determined with a further work up including imaging and laboratory values. Due to the patients age and community living situation infection is highly suspected.

Obesity Case Study

1. What three medication is the patient taking for hypertension?
   • Hydrochlorothiazide (HCTZ) 12.5 mg PO QD (Thiazide Diuretic)
   • Benazepril 10 mg PO QD (ACE Inhibitor)
   • Doxazosin 100 mg PO QD (Alpha-1adrenergic blocker)

2. Identify ten Risk factors for obesity in this case study.
   • Depression
   • Family History
   • Trend Dieting
   • Dietary Habits
   • Hypothyroidism
   • Sedentary Lifestyle
   • Bilateral Osteoarthritis of Knees
   • Stress
   • TAH (Hormone Imbalnces)
   • Ethnicity

3. Health consequences of patients with obesity:
   • CVD
   • OSA/Asthma
   • Cancer
   • GERD
   • Diabetes Mellitus II
   • Chronic Pain/Osteoarthritis
   • Depression
   • Pancreatitis
   • PVD
   • Cholecystitis

4. Does the patient have evidence of liver dysfunction?

No, the patient’s liver functions tests (LFTs) are within normal ranges. Total bilirubin and ALT are on higher ranges of normal (McCance & Huether, 2014).

• AST: 14 units/L (5-40 units/L)
• ALT: 29 units/L (5-35 units/L)
• Bilirubin/total: 0.9mg/dL (<1.0mg/dl)

5. Besides stating patient is short of breath, does the patient have any signs of abnormal pulmonary function at this time?

Yes, the patient is most experiencing pulmonary dysfunction. She specifically states that she cannot exercise d/t exercise intolerance. Her vital capacity (VC) is within a normal range 3-5 L but her total lung capacity (TLC) is slightly below normal at 5 L (normal being ~ 6L). Her expiratory reserve volume (ERV) is slightly low at 1L with normal is 1.1 L (Nagelhout, 2018) This could be indicative of the patient’s body habitus restricting her breathing. Obesity also leads to an increase of oxygen consumption and increase of CO2 production; her blood gas values are normal but over time compensatory mechanisms may be compromised (Barash, 2017).

6. Does this patient’s hypothyroid medication need a dose adjustment at this time?

At this time her thyroid stimulating hormone (TSH) level is normal at 3.7 mcg/ml (Normal: 0.4-4.8 mcg/ml). A high level of TSH may indicate an underactive thyroid. She is on a low dose of levothyroxine and her TSH is on the higher end of normal therefore it would be beneficial to increase the dose to see if it benefited her clinical state and her desire to lose weight. Furthermore, per the American Thyroid Association, the goal for TSH levels with patients on hormone replacement therapy is 0.5-2.5 mcg/L (2019).

7. What obesity classification does this patient belong to?

The patients BMI is 54.8 kg/m2 (>40kg/m2) which would classify this patient in the obesity class III (Barash, 2017).

8. What is the patients risk for developing disease if she continues at this weight?

Patient is at a very high risk for developing disease if she does not lose weight. There are many risk factors that this patient has including family history, HTN, and sedentary lifestyle that puts her at increased risk for cardiovascular disease. For example, currently she is on 3 medications for her high blood pressure but her blood pressure during her visit was still elevated at 138/88. This could lead to atherosclerosis and vessel damage that could eventually cause a myocardial infarction (MI) or cerebral vascular accidents (CVA). Other disorders and disease states like cancer, chronic pain, asthma, insulin resistance, diabetes and infertility have been correlated with obesity (McCance & Huether, 2014).

9. Calculate the BF% in this patient.

(1.2 (54.8) + 0.23 (57)) – (10.8 (0) – 5.4) = (65.8 + 13.1) – (0 -5.4) =

73.5%

Body fat percentage = 1.2 (BMI) + 0.23 (age) – 10.8 (gender) – 5.4, where the units for age are years and gender is equal to 1 for males and 0 for females. (Deurenberg, Weststrate & Seidell, 1991)

Patient Counseling:

“Ms. B. L. I want to commend you on your desire to lose weight and live a healthier lifestyle. It takes a lot of courage to address health concerns especially in regard to one’s weight. While surgery is a viable option to achieve your goals, I think that there are some non-surgical options we should discuss before we commit to surgery. Lifestyles modifications like dietary changes and increased activity may give you less invasive and more sustainable results. Perhaps we can address the things that are impeding you progress in these changes like your knee pain and food choices before we turn to surgery. I would like to refer you to a nutritionist and physical therapist to start you on a program to get your weight loss journey jump started. The physical therapist may be able to suggest activities that will not exacerbate your knee pain. After attempting to lose weight for 3 months we will reassess. Regardless of having surgery or not, candidates who have bariatric procedures need to show they are capable of losing weight with diet and exercise before they proceed to the operating room. After exploring these non-surgical options then we can readdress your desire to know more about bariatric surgery. I know you can achieve your goals and once you do your life will change for the better. Once you achieve your goals, I think you will be happier, and you will have a reborn zeal for life!

Q and A: TSH (thyroid stimulating hormone)

This component of the Retrieval Exercise is worth a total of 50 points [Case Studies (50) + Online Multiple Choice (50)] = 100 total points

1. Review each of the case studies provided.

2. For both Constipation (15 Points) & Increasing Confusion Case Studies (15), answer the questions below:

• Explain the primary pathophysiology of  case. (5 points)
• Using the information from the CC, HPI and Physical Assessment Examination, what are three differential diagnosis for this patient? In table format, list the pertinent positives and pertinent negatives for EACH of the 3 diagnosis (5 points)
• In 1 or 2 sentences, explain which of the three is the most likely diagnosis? Use the rationale in the total assessment findings above to guide your answer. (3 points)
• What parts of the exam would you like to perform? Label all the systems that are appropriate to assess from the lists provided in the case study. (2 points)

3. Obesity- Bruyere Case Study # 98- also attached here (20 Total Points)

• Answer questions: #1-9 (2 points each)
• Share the words that as a careprovider  you might offer to the patient as they move forward with their self care. (2 points)

5. Complete the online multiple-choice exam questions at your designated sign up time. (50 points)

References

• Andrews, C. N., & Storr, M. (2011). The Pathophysiology of Chronic Constipation.
  
  Canadian Journal of Gastroenterology
  
  . doi:10.1155/2011/169319
• Barash, P. G., Cullen, B. F., Stoelting, R. K., Cahalan, M. K., Stock, M. C., & Ortega, R. (2017).
  
  Clinical anesthesia.
  
  (8
  
  ^th
  
  ed.). Philadelphia, PA:  J.B. Lippincott.
• Deurenberg, P., Weststrate, J. A., & Seidell, J. C. (1991). Body mass index as a measure of body fatness: Age- and sex-specific prediction formulas.
  
  British Journal of Nutrition,65
  
  (02), 105. doi:10.1079/bjn19910073.
• McCance, K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2014).
  
  Pathophysiology: The biologic basis for disease in adults and children
  
  . St. Louis, MO: Elsevier.
• Nagelhout, J. J. (2018).
  
  Nurse anesthesia
  
  (6th ed.). St. Louis: Elsevier.