Patient: [Patient Name]
Date: [Date of Encounter]
I. Chief Complaint:
Constipation (define by frequency – e.g., fewer than 3 bowel movements per week)
Straining during bowel movements
Feeling of incomplete evacuation
Hard stools
Abdominal pain or bloating
II. History of Present Illness:
Duration of constipation symptoms (acute or chronic)
Any changes in bowel habits (recent decrease in frequency)
Presence of blood in stool (hematochezia)
Severity of symptoms (impacting daily life)
Use of laxatives (type, frequency, effectiveness)
III. Past Medical History:
Underlying medical conditions (diabetes, thyroid disorders, neurological disorders)
Previous surgeries (abdominal or pelvic)
History of constipation or other bowel problems
IV. Social History:
Diet (fiber intake, fluid intake)
Physical activity level
Medications (opioids, antidepressants, some medications can cause constipation)
V. Physical Exam:
Vital signs: (BP, HR, RR, Temp)
Abdominal exam:
Distention
Tenderness
Masses
Digital rectal exam (DRE) – may be performed if clinically indicated
Stool consistency
Hemoccult test (checks for occult blood)
VI. Assessment:
Functional constipation (most common type) vs. secondary constipation due to underlying medical condition or medication
Risk factors for constipation (diet, inactivity, medications)
Severity of constipation (impaction possible)
VII. Plan:
Treatment plan focuses on lifestyle modifications and dietary changes first:
Increased dietary fiber intake (fruits, vegetables, whole grains)
Adequate fluid intake (water is best)
Regular physical activity
Establishing a regular toileting routine
Laxatives (if lifestyle changes are not effective):
Bulk-forming laxatives (psyllium, fiber supplements)
Osmotic laxatives (magnesium citrate, polyethylene glycol)
Stimulant laxatives (bisacodyl, senna) – use with caution due to potential for dependence
Discuss appropriate use of laxatives and potential side effects.
Referral (if indicated):
Gastroenterologist for evaluation of suspected secondary constipation or severe constipation not responding to conservative measures.
VIII. Notes:
Include any additional observations or concerns, such as patient’s understanding of the recommendations, ability to make lifestyle changes, and emotional impact of constipation.
IX. Resources:
Consider providing patient education materials on constipation from reputable sources (e.g., American College of Gastroenterology, National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)).