PLAB 2 Case Scenario: Postoperative Constipation Management

Summary:

This case scenario involves a patient who has undergone leg surgery and is experiencing severe postoperative constipation. The focus is on effective history-taking, understanding the severity of the condition, and implementing an appropriate management plan while ensuring effective communication and patient-centered care.

Key Points:

History Taking:

• Confirm patient details (name, age, reason for admission).

• Utilize given information to establish context (e.g., recent leg fracture surgery).

• Ask open-ended questions to allow the patient to express their concerns fully.

• Identify the duration of constipation – four days is significant and requires immediate attention.

• Assess severity by asking about associated symptoms (bloating, pain, nausea, vomiting, or inability to pass gas).

• Explore red flags such as signs of obstruction, peritonitis, or toxic megacolon.

Medical and Medication History:

• Current medication review: Ask about all medications, not just those relevant to pain management.

• Long-term conditions: Hypertension, diabetes, or neurological disorders may contribute to constipation.

• Surgical history and complications: Ensure no postoperative issues affecting bowel function.

Lifestyle and Bowel Habits:

• Pre-surgery bowel routine: Was the patient regularly passing stools before?

• Dietary habits: Fiber intake and hydration status.

• Physical activity levels: Postoperative immobility can worsen constipation.

Important Considerations:

• Recognizing severity: Four days without bowel movement post-surgery is critical.

• Medication-induced constipation: Likely due to opioids such as Cocodamol.

• Primary recovery goal: Addressing constipation to ensure smooth surgical recovery.

• Patient expectations: Immediate relief is a priority for the patient.

Diagnostic Approach:

1. Focused abdominal examination:

   • Look for signs of distension, tenderness, or abnormal bowel sounds.

   • Check for palpable fecal masses.

2. Assess for complications:

   • If severe, consider imaging (abdominal X-ray) to rule out obstruction.

3. Basic investigations (only if needed):

   • Blood tests (electrolytes, inflammatory markers) if systemic symptoms are present.

Management Plan:

1. Immediate relief:

   • Phosphate enema for rapid relief.

2. Prevent recurrence:

   • Introduce laxatives (e.g., lactulose or macrogol) to maintain regular bowel movements.

3. Address underlying cause:

   • Modify pain management: Consider alternatives with fewer gastrointestinal side effects.

4. Encourage non-pharmacological interventions:

   • Increase fluid intake and dietary fiber (once oral intake is appropriate).

   • Promote early mobilization as tolerated.

5. Reassess and escalate if needed:

   • If no improvement, consider escalation to senior review.

Communication Skills:

• Use patient-friendly language to explain the issue and management.

• Empathy and reassurance: Acknowledge distress and discomfort.

• Patient autonomy: Ensure patient agreement with the management plan.

• Clarify concerns: Allow the patient to express worries and address them effectively.

Ethical Considerations:

• Informed consent: Explain procedures like enemas clearly.

• Shared decision-making: Engage the patient in choosing the best pain management strategy.

• Respect for patient’s concerns: If resistant to medication changes, offer alternative options or discuss with senior colleagues.

Additional Resources:

• GMC Good Medical Practice guidelines on patient communication and shared decision-making​.

• PLAB 2 Examiner Tips: Effective time management, structured consultations, and avoiding over-explanation​.

• Understanding your PLAB 2 Results: Importance of interpersonal skills, diagnosis, and management in scoring well​.

This structured approach ensures effective clinical reasoning, patient-centered care, and optimal performance in PLAB 2 stations. 🚀