Personal Details:
Name: Mrs Jean Taylor
Age: 79
Medical Record:
Past medical history: Total hip replacement 4 days ago.
Regular medication: Co-codamol for pain.
Notes:
A 79-year-old woman who had a hip replacement 4 days ago is complaining of constipation. She has not opened her bowels since her admission 4 days ago. Her pain is well-controlled, and she is otherwise stable. She is worried and uncomfortable.
Task:
1. Take a focused history.
2. Perform a relevant examination.
3. Discuss the likely cause and management of her constipation.
Examination: soft but distended abdomen with normal bowel sounds and an empty rectum.
Opening Sentence: “Doctor, I’m so uncomfortable. I haven’t been to the toilet properly for four days now, and my tummy feels really bloated.
Open History (to give freely): “I had my hip operation four days ago. Before I came into the hospital, I was very regular, once a day. But I haven’t had a proper bowel movement since I arrived. I can pass wind, but that’s it. I’m drinking plenty, but nothing is happening.”
ICE (Ideas, Concerns, Expectations):
Ideas: “I think just being in the hospital and not moving around.”
Concerns: “Is it a blockage? Am I going to need an operation for this as well?”
Expectation: “I want something to help me go to the toilet. I feel awful.”
How to Act: You are uncomfortable, bloated, and a bit miserable. You are usually fit and active, so you find this frustrating.
More History (only if asked): You have no nausea or vomiting. Your appetite is a bit reduced. You have no significant past medical history apart from the arthritis that led to your hip replacement. You are passing flatus, okay. You are passing urine, okay. You are drinking okay. You can eat, but you are trying to eat a little until you open your bowels.
Social History: Lives alone, fully independent before her fall.
Questions to ask:
“So it’s not a serious blockage?”
“What is a suppository?”
History of Presenting Complaint:
You mentioned you feel bloated and haven’t been to the toilet. When was the last time you opened your bowels?
Is this a change from your normal pattern? What is normal for you?
Are you having any abdominal pain?
Have you been able to pass wind?
Have you felt sick or been sick?
Exploring Contributing Factors:
Can we look at your medication chart? I see you are on co-codamol for pain.
How has your appetite been since the operation?
How much have you been able to drink?
How has the physiotherapy been going? Are you managing to get out of bed and walk a little?
ICE (Ideas, Concerns, Expectations):
What were your own thoughts on why you might be so blocked up?"
What was your biggest worry about it?
You said you need something to get you going. What have you tried in the past for constipation?"
Explain the situation, the likely diagnosis or DD:
Mrs Taylor, it’s very common to experience constipation after a major operation like a hip replacement, but it’s very uncomfortable, and we need to get it sorted for you.
(After examination, which would show a soft but distended abdomen with normal bowel sounds and an empty rectum)
I’ve examined your tummy, and it’s soft, which is good. It doesn’t feel like there is a serious blockage. You are right, the main cause of this is the co-codamol you are taking for pain. The ‘co’ part stands for codeine, which is a strong painkiller that is very well known for causing constipation. The fact that you are not moving around as much as usual also slows the bowel down.”
Addressing and answering the patient’s ICE:
You’re worried about a blockage. Because you are still passing wind and your tummy is soft, a serious blockage is very unlikely. This is a very common side effect of the painkillers, and we have simple and effective ways to manage it.
Next Steps:
The first thing we need to do is start you on some regular laxatives. We will give you a gentle laxative (Movicol, Fybogel, or senna) that softens the stool and another one that stimulates the bowel to move. We should also think about your pain relief. Now that you are a few days post-op, we might be able to reduce the co-codamol and use more paracetamol, which don’t cause constipation.”
It’s great that you are drinking plenty of fluids, so please keep that up. The physiotherapists will be getting you up and walking with a frame, and as you start to move more, that will also help your bowels to wake up.
If the oral laxatives don’t work within a day or so, the next step would be to use a suppository. This is a small, waxy pellet of medication that we insert into your back passage. It works directly on the lower bowel to make it empty. It’s very effective and works quickly. Our goal is to get you comfortable and back to your normal routine as soon as possible.
Addressing ideas, concerns, and expectations: Reassure her that a serious blockage is unlikely. Confirm her suspicion that the painkillers are the main culprit. Explain the plan to manage the constipation.
The management is a stepwise approach to constipation. 1. Prescribe a combination of softening and stimulant laxatives. 2. Review analgesia and reduce opiate use if possible. 3. Encourage fluids and mobility. 4. Explain the next step if oral laxatives fail (suppository or enema).
What is scenario testing? This is a common post-operative care scenario. It tests the candidate’s knowledge of the causes and management of post-operative constipation. The key is to identify the opiate analgesia as the primary cause and to formulate a clear, stepwise management plan, while providing reassurance.