constipation
Doctor Information
Alice Mitchell, age 12
PMH
Cerebral Palsy
PEG tube insertion 2005
Infantile seizures
Drug History
Fortijuice 200ml tds
Thick and Easy 500g additive
Baclofen 5g tds
No allergies
PMH
Cerebral Palsy
PEG tube insertion 2005
Infantile seizures
Drug History
Fortijuice 200ml tds
Thick and Easy 500g additive
Baclofen 5g tds
No allergies
Patient Information
Alice Mitchell age 12
You are Margaret Mitchell, Alice’s mother
Opening line: I’ve come about Alice, I think she is constipated
History: Alice is usually quite regular with her bowels, but this week she hasn't had a dirty nappy in 5 days. She seems to be in pain hasn't really been herself, and yesterday at day therapy she refused lunch which is very unusual. Alice normally has a dirty nappy once if not twice a day, and because of her PEG feeds, her poo is usually on the runny side. You did notice that she looks sometimes like she is trying to go, and you have seen some smears in her nappy this week. She has not soiled herself, and is passing urine normally.
If asked only: Alice does take some things orally, like juice and yoghurt, but gets the bulk of her nutrition from her PEG feeds. She has been in a wheelchair since she was a toddler but has some head control and hand control. Three days a week she attends day therapy where she does a bit of schooling and physiotherapy. It is good because she can spend some time with other children there. At home you are her main carer. You manage fine as you do not work. Her brother Jeff is 22 and lives nearby, and her dad is with you at home. She needs help will all her cares, but thankfully you have a hoist at home, and an adapted bungalow so things are not too difficult.
Alice had a difficult birth, she got stuck and it took a long time to get her out. Afterwards she started having seizures and was diagnosed with cerebral palsy. Her seizures stopped when she was 8 and she is not on any medication for this anymore. She is fully immunised and the only things you give her are thickeners for oral fluids so she doesn't choke. She has open access to the Hospital but has not often been in.
If asked about yourself, you are grateful for the doctors concerns but you are coping very well. You decided a long time ago that even though Alice is disabled, she can still have fun and a good quality life, and you enjoy being with her. You get to see your own friends every week when Alice is at day therapy.
Ideas: Alice is constipated, although you really don't know why - nothing has changed recently
Concerns: You don’t want things to get worse, she is already in pain from it
Expectations: you probably need some medication to sort this out
You would appreciate an explanation for the constipation and how you can stop it happening again. You are happy to use laxatives but want a good plan for follow-up in case there are any problems.
You are Margaret Mitchell, Alice’s mother
Opening line: I’ve come about Alice, I think she is constipated
History: Alice is usually quite regular with her bowels, but this week she hasn't had a dirty nappy in 5 days. She seems to be in pain hasn't really been herself, and yesterday at day therapy she refused lunch which is very unusual. Alice normally has a dirty nappy once if not twice a day, and because of her PEG feeds, her poo is usually on the runny side. You did notice that she looks sometimes like she is trying to go, and you have seen some smears in her nappy this week. She has not soiled herself, and is passing urine normally.
If asked only: Alice does take some things orally, like juice and yoghurt, but gets the bulk of her nutrition from her PEG feeds. She has been in a wheelchair since she was a toddler but has some head control and hand control. Three days a week she attends day therapy where she does a bit of schooling and physiotherapy. It is good because she can spend some time with other children there. At home you are her main carer. You manage fine as you do not work. Her brother Jeff is 22 and lives nearby, and her dad is with you at home. She needs help will all her cares, but thankfully you have a hoist at home, and an adapted bungalow so things are not too difficult.
Alice had a difficult birth, she got stuck and it took a long time to get her out. Afterwards she started having seizures and was diagnosed with cerebral palsy. Her seizures stopped when she was 8 and she is not on any medication for this anymore. She is fully immunised and the only things you give her are thickeners for oral fluids so she doesn't choke. She has open access to the Hospital but has not often been in.
If asked about yourself, you are grateful for the doctors concerns but you are coping very well. You decided a long time ago that even though Alice is disabled, she can still have fun and a good quality life, and you enjoy being with her. You get to see your own friends every week when Alice is at day therapy.
Ideas: Alice is constipated, although you really don't know why - nothing has changed recently
Concerns: You don’t want things to get worse, she is already in pain from it
Expectations: you probably need some medication to sort this out
You would appreciate an explanation for the constipation and how you can stop it happening again. You are happy to use laxatives but want a good plan for follow-up in case there are any problems.
Examination Findings
Mrs Mitchell will help transfer Alice to the examination couch and consent to her examination.
Pulse 88
Mouth moist, capillary refill <2 secs
Temperature 36.8
Alert and moving all limbs
Chest clear
Abdomen soft but feels quite full. No guarding or tenderness. Nappy dry.
Pulse 88
Mouth moist, capillary refill <2 secs
Temperature 36.8
Alert and moving all limbs
Chest clear
Abdomen soft but feels quite full. No guarding or tenderness. Nappy dry.
Mark scheme
Data Gathering
|
POSITIVE INDICATORS
Organised and systematic in gathering information from history taking, examination Identifies abnormal findings or results and/or recognises their implications. Asks about red flag symptoms Data gathering does appears to be guided by the probabilities of disease Undertakes physical examination competently (but does not suggest or perform rectal examination |
NEGATIVE INDICATORS
Makes immediate assumptions about the problem Intervenes rather than using appropriate expectant management Is disorganised/unsystematic in gathering information Data gathering does not appear to be guided by the probabilities of disease. Appears disorganised/unsystematic in the application of the instruments or the conduct of physical examinations |
Clinical Management Skills
|
POSITIVE INDICATORS
Makes appropriate diagnosis of constipation Develops a management plan (including prescribing and referral) that is appropriate and in line with current best practice Makes plans that reflect the natural history of common problems Management approaches reflect an appropriate assessment of risk Makes appropriate prescribing decisions Refers appropriately & co-ordinates care with other healthcare professionals Manages risk effectively, safety netting appropriately Encourages improvement, rehabilitation, and, where appropriate, recovery. Encourages the patient to participate in appropriate health promotion and disease prevention strategies Follow-up arrangements and safety netting are adequate |
NEGATIVE INDICATORS
Fails to consider common conditions in the differential diagnosis Does not suggest how the problem might develop or resolve Fails to make the patient aware of relative risks of different approaches Decisions on whether/what to prescribe are inappropriate or idiosyncratic. Decisions on whether & where to refer are inappropriate. Follow-up arrangements are absent or disjointed Fails to take account of related issues or of co-morbidity Unable to construct a problem list and prioritise Unable to enhance patient’s health perceptions and coping strategies |
Inter Personal Skills
|
POSITIVE INDICATORS
Identify patient’s agenda, health beliefs & preferences / does makes use of verbal & non-verbal cues. Works with the patient and carer to develop a shared management plan Uses explanations that are relevant and understandable to the patient Shows sensitivity for the patient’s feelings in all aspects of the consultation including physical examination Shows commitment to equality for all |
NEGATIVE INDICATORS
Doesn't enquire about patients ICE Takes a doctor centered approach towards management Uses an explanation that is filled with jargon, or forgets to explain at all Doesn't show any sympathy / empathy towards the patient's situation Quick to judge, or seems awkward in dealing with a disabled child |
Management
Explanation: Constipation in children is very common, and often there is no specific cause. The main problems are passing harder and fewer stools than normal, with pain or soiling. Sometimes hard poo can stuck at the end of their bowel, and this can be more difficult to get rid off and cause more symptoms. There are several different treatments that have shown to be very effective to treat this problem.
The diagnosis of constipation is from the history and examination. You need to rule out any underlying cause by checking red flag symptoms (symptoms from birth, meconium not passed within 24 hours, ribbon stools, leg weakness, failure to thrive). However. do NOT perform a rectal exam in children.
First thing is giving mum some information - there are a lot of good leaflets out there or you can print one from patient.co.uk. Although diet and lifestyle factors alone are not recommended, there is no harm is doing these alongside laxatives, which may need to be taken for several months. Simple things like having more fluids (preferably not carbonated), more fibre, and more exercise will help in the longer term. The NICE CKS website has a list of recommended fluid intake per age group which is very useful. Having regular toileting and even a reward system for a bowel movement may also help (although in this case it might be a bit more challenging).
Next thing is to decide whether the child is impacted or not. If the symptoms are severe and there is a history of overflow or soiling, or you can actually feel lumpy faeces when you palpate their abdomen, then impaction is likely. The recommended laxative is a macrogol - so movicol paediatric. The disimpaction regime is an escalating dose of movicol starting with 2 sachets daily, increasing by two sachets a day up to 8 sachets. This must be continued until a type 7 stool appears. Check with the BNF to ensure your dosing is correct with the age of the child. As soon as the bowel is clear, use a maintenance regime (usually 1-2 sachets daily for the next couple of months. Follow the child up after one week, then regularly until settled.
If the child is not impacted, commence on 1-2 sachets daily, and adjust the dose depending on response. Again, close monitoring is required, and it is quite useful to get health visitors or school nurses involved.
The diagnosis of constipation is from the history and examination. You need to rule out any underlying cause by checking red flag symptoms (symptoms from birth, meconium not passed within 24 hours, ribbon stools, leg weakness, failure to thrive). However. do NOT perform a rectal exam in children.
First thing is giving mum some information - there are a lot of good leaflets out there or you can print one from patient.co.uk. Although diet and lifestyle factors alone are not recommended, there is no harm is doing these alongside laxatives, which may need to be taken for several months. Simple things like having more fluids (preferably not carbonated), more fibre, and more exercise will help in the longer term. The NICE CKS website has a list of recommended fluid intake per age group which is very useful. Having regular toileting and even a reward system for a bowel movement may also help (although in this case it might be a bit more challenging).
Next thing is to decide whether the child is impacted or not. If the symptoms are severe and there is a history of overflow or soiling, or you can actually feel lumpy faeces when you palpate their abdomen, then impaction is likely. The recommended laxative is a macrogol - so movicol paediatric. The disimpaction regime is an escalating dose of movicol starting with 2 sachets daily, increasing by two sachets a day up to 8 sachets. This must be continued until a type 7 stool appears. Check with the BNF to ensure your dosing is correct with the age of the child. As soon as the bowel is clear, use a maintenance regime (usually 1-2 sachets daily for the next couple of months. Follow the child up after one week, then regularly until settled.
If the child is not impacted, commence on 1-2 sachets daily, and adjust the dose depending on response. Again, close monitoring is required, and it is quite useful to get health visitors or school nurses involved.