Focused SOAP Note
Patient: G.B.
SUBJECTIVE
CC: “I’m having problems going to the bathroom…I’m constipated.”
HPI:
The patient is a 57-year-old African American male with a past medical history of coronary artery disease (CAD), hypertension, and hyperlipidemia being treated in a sub-acute care facility. He was admitted to the facility five days ago after Coronary Artery Bypass Grafting (CABG). He has not experienced any complications during his stay, although the nurse noted that he has not had a bowel movement in the last three days. The patient presents in good health, although he admits to having some abdominal discomfort and bloating, with having to strain when he uses the restroom. He states that he usually takes a full glass of Metamucil every day to help “get him going,” but he has not had that since going in for surgery nearly a week ago.
PMH:
Coronary Artery Disease (CAD) (2017)
Hypertension (2017)
Hyperlipidemia (2016)
Melanoma (early 2000s)
Appendicitis (1970s)
Surgery: CABG (7/11/2022)
Melanoma removal, left upper thigh (2001)
Appendectomy (1972)
Health Immunizations: Influenza, COVID; up to date on childhood vaccines
Medications:
-Metoprolol 100 mg PO BID (beta blocker)
-Pravastatin 40 mg PO QD (lipid lowering medication)
-Bisacodyl 10mg rectal suppositories PRN for constipation
-Aspirin 81 mg PO QD (antiplatelet therapy)
-Morphine IV 0.1 mg per kg every 4 hours PRN for pain management
Allergies:
-Denies medication, food, latex, or environmental allergies
Family History:
-Father (Deceased, age 56 from heart attack) HTN, HF, Smoker
-Mother (Living, age 80) Colon cancer, Hyperlipidemia
-Paternal grandfather (Deceased, age 45 due to HF)
-Paternal grandmother (Deceased, age 58 due to HF)
-Maternal grandfather (Deceased, age 82 from natural causes) Colon cancer
-Maternal grandmother (Deceased, age 63 from car accident) Hyperlipidemia
Social History:
Housing/living situation: Lives with his wife and youngest son in a middle-income neighborhood
Relationship/Marital status: Married (28 years ago)
Family/Support/Relationships: He has four adult children: one son lives with him, one son is
enrolled in college out-of-state, one daughter is enrolled in college nearby, and one son lives nearby and is married with a daughter. He reports he has a strong social support system.
Substance use: Denies alcohol consumption, illicit substance use, and history of smoking.
Diet: Eats three meals a day that include plenty of fruits, veggies, whole grains, lean proteins,
and low-fat dairy; drinks six to eight glasses of water daily. Breakfast: low-fat yogurt with granola and fruit, whole-grain toast; lunch: chicken salad wrap, low-fat mayo, fruit (banana or apple); dinner: chicken breast or fish (salmon), with vegetables (e.g., sweet potato, broccoli, squash, baby carrots, etc.).
Exercise: He has been unable to exercise lately without being out of breath due to CAD.
Sleep: Reports sleeping eight hours a night normally, but has been having some issues sleeping
since his surgery.
ROS:
Constitutional: Denies fever, fatigue, weight gain, or dizziness.
Respiratory: Denies cough and shortness of breath.
Cardiovascular: Denies palpitations, chest pain, and lower leg edema.
Gastrointestinal: Affirms constipation, see HPI.
Genitourinary: Denies dysuria, hematuria, urinary frequency, or difficulty urinating.
OBJECTIVE
Vital signs: Temp: 98.7℉• BP: 122/87 mmHg• HR: 72 bpm• RR: 13• Sat: 98% on room air • Weight: 187.5 lbs (BMI: 24.8 kg/m2)
Physical Examination:
General: Patient is lying in bed, looks somewhat uncomfortable, although normal skin pallor
and turgor.
Cardiovascular: S1 and S2 audible on auscultation, regular rate and rhythm (RRR); no rubs,
murmurs, gallops, clicks, or cardiomegaly. Carotid arteries 2+ upon palpation, no thrill
bilaterally. Peripheral pulses brachial, dorsalis pedis, radial, and posterior tibial pulses 2+
bilaterally. Upon auscultation, no bruit in iliac renal or femoral arteries bilaterally.
Respiratory: There is no visible respiratory distress; lungs clear to auscultation and percussion.
Gastrointestinal: High pitched bowel sounds in all four quadrants; moderate diffuse tenderness
without rebound or guarding; mild distention. No evidence of masses, hernia, or
organomegaly.
Genitourinary: No palpable protrusions bilaterally in inguinal canals; prostate surface is firm
with no nodules upon palpation.
ASSESSMENT
Constipation (K59.00)
Patient presents with symptoms of constipation, so this is the likely diagnosis.
CAD (I25. 10)
Controlled on Aspirin 81 mg PO QD
HTN (I10)
Controlled on Metoprolol 100 mg PO BID
Hyperlipidemia (E78. 5)
Controlled on Pravastatin 40 mg PO QD
PLAN
Constipation
-Order x-ray of abdomen and labs (CBC, CMP, TSH)
-Order CT of abdomen
-Prescribed Colace 200 mg daily divided in two doses daily (total 400 mg)
-May require Fleet enema 19 grams-7 grams/133 ml, instilling 133 ml rectally if no bowel movement
-Recommend increasing fiber intake with adequate fluid intake (six to eight glasses daily)
-Referral to Gastrointestinal (GI) Specialist
CAD
-Continue Aspirin 81 mg PO QD
HTN
-Continue Metoprolol 100 mg PO BID
Hyperlipidemia
-Continue Pravastatin 40 mg PO QD
EVIDENCE-BASED RATIONALE:
Diagnosis:
The final diagnosis is constipation (K59.00), which is characterized by pain or difficulty during defecation (without an identifiable organic cause) as well as lack of periodicity in defecating (Diaz et al., 2021). The causes of this condition are multifactorial, as it may be due to either an external or internal factor, whether the problem is stemming from the rectum or colon or due to environmental variables (Diaz et al., 2021). One reason for slow colonic motility is that they have been chronically abusing laxatives for many years, while other external causes include lack of adequate fluid intake, poor dietary habits (particularly a lack of fiber), or overusing certain medications; additional, there may be some endocrine issue, such as hypothyroidism (Diaz et al., 2021; Jani & Marsicano, 2018).
For the patient, he has admitted to taking Metamucil routinely, which is a laxative. He also has a history of eating unhealthy meals, although he did change these habits when he was diagnosed with CAD and hypertension. However, perhaps the most critical reason for his constipation is due to his recent surgery and subsequent pain management. He has been receiving intravenous (IV) morphine 0.1 mg per kg every four hours as needed to control his pain following surgery. According to Kokki et al. (2017), analgesics such as opioids, although frequently used to treat pain after surgery, are associated with many adverse effects such as vomiting, nausea, dizziness, somnolence, and of course, constipation. While many side effects may get better within a few days, constipation may continue, with opioid-induced constipation (OIC) being extremely harmful and potentially even delaying hospital discharge (Kokki et al., 2017).
Plan:
Labs to be Ordered:
-Complete Blood Count (CBC) w/Diff w/PLT
-Complete Metabolic Panel (CMP)
-Thyroid Stimulating Hormone (TSH) and T3, T4
Tests to be Ordered:
-X-ray of abdomen
– CT of abdomen
Additional Assessment:
First-line imaging modality for small bowel obstructions is the computed tomography (CT) scan of the abdomen, with intravenous (IV) contrast used for patients with normal renal function and no contraindications (Schick et al., 2021). This will rule out or confirm if there is some type of small bowel obstruction, such as a fecal impaction. Since this constipation is more than likely a combination of post-surgical pain management and functional immobility due to his recent CABG, it is expected that his condition will improve as his Morphine is reduced and he recovers from the surgery. Nonetheless, since he has admitted to having constipation while at home, a CT is warranted to rule out any serious causes. Red flags that must be identified include rectal bleeding, recent weight loss, fever, as well as peritoneal and/or neurological signs (Farney & Schmitz, 2019; McAninch & Smithson, 2017).
Pharmacological Treatment:
First line treatment for constipation – when it is not due to an underlying reason such as bowel obstruction – is the use of laxatives; these include bulk laxatives as well as polyethylene glycol 3350 (“PEG”), although these are used for more chronic constipation (Jani & Marsicano, 2018). For post-operative constipation, emollient stool softeners like docusate are preferred as a short-term treatment, so the patient will be prescribed Colace 200 mg daily divided in two doses daily (total 400 mg) (Jani & Marsicano, 2018). He may also require a Fleet enema if he is still unable to defecate, with 19 grams-7 grams/133 ml, instilling 133 ml rectally.
Non-pharmacological Treatment:
Non-pharmacological management for constipation includes several strategies, including behavioral changes along with medical supervision, as patients may require dietary instructions (Diaz et al., 2021). For diet, it is recommended that patients consume a normal fiber intake, while fluid intake must also be sufficient, with most people requiring six to eight glasses of water daily (depending upon their levels of exercise) (Diaz et al., 2021). Therefore, he will be encouraged to integrate more fiber into his diet, such as beans and lentils.
Referral:
-Gastrointestinal (GI) Specialist
Health Promotion:
The patient will be cautioned about taking Metamucil every day, as the overuse of laxatives can cause constipation. It is also important he understands the importance of never holding in a bowel movement, but always taking the time to defecate without feeling rushed or straining. He should also integrate more fiber into his daily diet.
Follow-Up
The patient should be closely monitored to see if the laxatives are successful, and the patient is able to have a normal bowel movement (Jani & Marsicano, 2018). He may require Miralax 17 g (diluted in eight fluid ounces water or juice, orally once daily) for chronic constipation, especially since he admits to taking Metamucil daily. However, if he does not respond to this treatment, anorectal testing is recommended to evaluate possible outlet dysfunction; this test is used to measure the rectal and anal pressure both at rest and during attempted defecation, assessing rectal sensation, rectal compliance, and recto-anal reflexes (Jani & Marsicano, 2018).
DIFFERENTIAL DIAGNOSES:
-Diverticulitis (K57. 92)
Diverticulitis is a condition where there is either inflammation or infection in one or more small pouches within the digestive tract (Carr & Velasco, 2021). It can be associated with bowel habit changes, while also causing constipation; additionally, the most common complaint of patients is lower left sided abdominal pain, which is usually described as crampy (Farney & Schmitz, 2019). Additionally, physical findings of diverticulitis may also include abdominal tenderness and/or distension, absent bowel sounds, a tender mass within the abdomen, as well as findings associated with fistula formation (Carr & Velasco, 2021). However, the patient’s abdominal discomfort is not located on the left side, but bilateral, while no masses were palpated upon abdominal examination.
-Hernia (K46. 9)
Hernias are considered a bulge, protrusion, or projection of an organ (or organ part) thought the body wall, with reducible hernias being soft and easily able to be put back through defect; on the other hand, an incarcerated hernia is painful, firm, and not reducible (Farney & Schmitz, 2019). Patients with hernias may complain of constipation; however, they usually also present with dull heaviness or pin in the genital region, with pain becoming more noticeable during straining or coughing (Farney & Schmitz, 2019). Again, as the patient’s abdominal examination did not reveal any bulges or protrusions, this condition is unlikely.
-Small Bowel Obstruction (K56. 699)
Small bowel obstruction is a condition where there is a mechanical blockage of the bowel, which may be due to several causes, including stool impaction, foreign bodies, inflammatory bowel disease (e.g., Crohn disease), or malignancy (Schick et al., 2021). Patients with this condition usually have abdominal pain, nausea, bilious vomiting, and distension, while obstipation – or the inability to pass stool or gas – may occur (Farney & Schmitz, 2019). During the abdominal examination, the patient’s stomach is tympanic upon percussion, while high-pitched bowel sounds can be heard upon auscultation (Farney & Schmitz, 2019). Furthermore, abdominal tenderness may be either focus or diffuse, with the presence of distention (Schick et al., 2021).
References
Carr, S., & Velasco, A. L. (2021). Colon Diverticulitis. StatPearls Publishing. https://www.
ncbi.nlm.nih.gov/books/NBK541110/
Diaz, S., Bittar, K., & Mendez, M. D. (2021). Constipation. StatPearls Publishing. https://www.
ncbi.nlm.nih.gov/books/NBK513291/
Farney, R., & Schmitz, G. (2019). Constipation Mimics: Differential Diagnosis and Approach to
Management. emDocs. http://www.emdocs.net/constipation-mimics-differential-
diagnosis-and-approach-to-management/
Jani, B., & Marsicano, E. (2018). Constipation: Evaluation and Management. Missouri medicine,
115(3), 236–240.
Kokki, M., Kuronen, M., Naaranlahti, T., Nyyssönen, T., Pikkarainen, I., Savolainen, S., &
Kokki, H. (2017). Opioid-Induced Bowel Dysfunction in Patients Undergoing Spine
Surgery: Comparison of Oxycodone and Oxycodone-Naloxone Treatment. Advances in therapy, 34(1), 236–251. https://doi.org/10.1007/s12325-016-0456-9
McAninch, S., & Smithson, C. C. (2017). Gastrointestinal Emergencies. In: C. Stone, R. L.
Humphries (Eds). CURRENT Diagnosis & Treatment: Emergency Medicine (8th edition).
McGraw-Hill.
Schick, M. A., Kashyap, S., & Meseeha, M. (2021). Small Bowel Obstruction. StatPearls
Publishing. https://www.ncbi.nlm.nih.gov/books/NBK448079/
