SOAP NOTE – Constipation

None were performed at this visit.

No labs indicated at this stage.

None required during this encounter.

o    1-Functional Constipation (ICD-10: K59.00) – Functional constipation is considered a differential diagnosis, especially in individuals with dietary and lifestyle factors that impair regular bowel movements (Kilgore & Khlevner, 2024). In this patient’s case, her recent history of low fiber intake, reduced water consumption, and limited physical activity following surgery all contribute to transient functional bowel slowing. Although she has no prior history of chronic constipation, these acute behavioral changes mimic the conditions under which functional constipation can manifest.

o    2-Postprocedural Ileus (ICD-10: K91.89) – Postprocedural ileus refers to a temporary impairment of bowel motility following surgical intervention. This is more common after intra-abdominal surgeries, but it can occur with any procedure involving anesthesia (Buchanan & Tuma, 2023). Symptoms include absent bowel movements, abdominal distention, and often nausea or vomiting. While this diagnosis is considered due to the patient’s recent procedure, it is less likely in this case. The presence of hypoactive bowel sounds (rather than absent), a soft non-tender abdomen, and no associated nausea or vomiting reduce the likelihood of ileus.

o    3- Functional Diarrhea (ICD-10: K59.1) – Functional diarrhea is ruled out as a potential diagnosis. The patient has no complaints of loose stools, increased stool frequency, urgency, or nocturnal bowel movements. Her condition reflects hypoactivity of the bowels rather than the hypermotility seen in diarrhea. Therefore, this diagnosis is inconsistent with her symptoms and has been excluded (Savarino et al., 2022).

Diagnosis

o Drug-induced constipation (ICD-10: K59.09) is the primary diagnosis. This condition is a well-documented side effect of opioid medications, particularly those prescribed postoperatively. Opioids exert their constipating effects by binding to μ-opioid receptors in the gastrointestinal tract, which leads to delayed colonic transit, reduced peristalsis, and harder stool consistency (Sizar et al., 2021). In this case, the patient began experiencing significant constipation shortly after initiating hydrocodone-acetaminophen therapy for postoperative pain, making the temporal relationship between medication use and symptom onset clinically significant. Her report of not having a bowel movement for six days, along with abdominal bloating and discomfort, aligns with the presentation of drug-induced constipation.

§   Further testing

At present, no further diagnostic testing is necessary due to the absence of alarming symptoms. However, if there is no bowel movement within 5 to 7 days or symptoms worsen, imaging studies or laboratory work will be considered for further evaluation.

§   Medication

The patient was prescribed Senna 17.2 mg to be taken orally twice daily for three days. She was advised to stop hydrocodone if pain permits and use acetaminophen instead. Over-the-counter docusate sodium was discussed as an optional stool softener.

§   Education

Education was provided on opioid-induced constipation, emphasizing how opioids impact gut motility. The patient was instructed on the proper use of laxatives and stool softeners, and the importance of fiber, fluid intake, and movement. She understood and agreed with all components of the care plan.

§   Non-medication treatments

She was advised to increase daily fiber intake (fruits, vegetables, whole grains), drink at least eight glasses of water, walk daily for physical activity, and try natural remedies like prune juice to promote regular bowel movements without relying solely on medications.

The patient was calm, attentive, and engaged during the consultation. She maintained good eye contact, asked appropriate questions, and clearly understood her diagnosis and treatment plan. She committed to following the plan and agreed to return if symptoms persisted or worsened.