1 00:00:00,000 --> 00:00:03,180 Tracey: the normal frequency of bowel movements is from three times 2 00:00:03,180 --> 00:00:05,220 per day to three times per week. 3 00:00:05,310 --> 00:00:08,400 What, like, how do you even answer that? 4 00:00:08,400 --> 00:00:10,220 That's like saying, it's either one or a million it's 5 00:00:10,220 --> 00:00:11,841 somewhere in there, that's nuts. 6 00:00:11,971 --> 00:00:14,515 I mean, How do you know if someone's constipated based on that? 7 00:00:22,110 --> 00:00:25,560 Joe: Welcome to the Evidence-Based Urgentology podcast from EB Medicine, 8 00:00:25,560 --> 00:00:27,840 where urgent care meets evidence. 9 00:00:27,950 --> 00:00:31,190 I'm Joe Toscano, senior research editor for Emergency Medicine Practice, 10 00:00:31,250 --> 00:00:33,980 and a member of the evidence-based Urgent Care editorial board. 11 00:00:35,285 --> 00:00:36,785 Tracey: Hi there, and I'm Tracy Davidoff. 12 00:00:36,785 --> 00:00:40,055 I'm editor in chief of Evidence-Based Urgent Care, and we're practicing 13 00:00:40,055 --> 00:00:42,935 urgent care physicians with years of experience, probably too many years 14 00:00:42,935 --> 00:00:44,675 of experience, on the front lines. 15 00:00:44,735 --> 00:00:48,605 And for us, diagnosis is detective work and the clues are in the history, 16 00:00:48,605 --> 00:00:50,315 the exam, and of course the evidence. 17 00:00:50,555 --> 00:00:52,715 That thrill of solving the patient's puzzle is really 18 00:00:52,715 --> 00:00:53,855 what keeps us coming back. 19 00:00:54,490 --> 00:00:58,930 Joe: Each month we unpack the latest issue of evidence-based urgent care tackling 20 00:00:58,930 --> 00:01:00,730 common chief complaints from presentation. 21 00:01:00,730 --> 00:01:04,600 Through diagnosis to disposition, we highlight the best evidence, the key 22 00:01:04,600 --> 00:01:05,830 takeaways, and the clinical pearls. 23 00:01:06,700 --> 00:01:09,820 Tracey: And by the end of every episode, you'll have sharper skills, deeper 24 00:01:09,820 --> 00:01:13,540 knowledge, and more sound strategies that you can use on your very next shift. 25 00:01:13,930 --> 00:01:14,890 So let's dive in. 26 00:01:14,890 --> 00:01:16,030 The evidence starts now. 27 00:01:16,180 --> 00:01:21,460 And remember, you can always find more at www.ebmedicine.net. 28 00:01:21,958 --> 00:01:22,648 Joe: Hi everybody. 29 00:01:23,048 --> 00:01:25,958 Tracey: Good evening, good morning, good afternoon, or whatever it is 30 00:01:25,958 --> 00:01:27,218 that you're doing right about now. 31 00:01:27,618 --> 00:01:29,208 Thank you so much for joining us. 32 00:01:29,428 --> 00:01:32,218 We are gonna talk today about poop. 33 00:01:32,938 --> 00:01:35,038 Yes, we are gonna talk about poop today. 34 00:01:35,038 --> 00:01:36,358 I know it's gonna be boring. 35 00:01:36,538 --> 00:01:38,728 We're gonna try to make it as exciting as possible. 36 00:01:39,162 --> 00:01:43,855 This month's episode is urgent Care Evaluation and Management of Constipation. 37 00:01:44,655 --> 00:01:48,185 Believe it or not this was an update from an emergency medicine 38 00:01:48,215 --> 00:01:51,255 episode and, Dr. Joseph Toscano. 39 00:01:51,315 --> 00:01:51,885 Yay. 40 00:01:51,885 --> 00:01:55,675 Dr. Toscano, my co-host was the lucky person who got to 41 00:01:55,675 --> 00:01:57,385 update the article about poop. 42 00:01:57,785 --> 00:01:58,895 Or the lack thereof. 43 00:01:59,180 --> 00:01:59,660 Joe: There you go. 44 00:01:59,765 --> 00:02:03,545 Tracey: So thank you so much for Joe for taking that on so that I didn't have to. 45 00:02:03,885 --> 00:02:04,995 So Joe did that. 46 00:02:04,995 --> 00:02:07,433 And then we had our peer reviewer with Sean McNeely. 47 00:02:07,658 --> 00:02:09,338 Thank you so much for reading about. 48 00:02:10,133 --> 00:02:11,093 Poop. 49 00:02:11,393 --> 00:02:11,843 All right. 50 00:02:11,843 --> 00:02:12,953 So we're gonna do this. 51 00:02:12,953 --> 00:02:16,253 I'm gonna ask the questions and Joe is gonna give us the answers. 52 00:02:16,253 --> 00:02:18,443 And we're gonna talk a little bit about this. 53 00:02:18,773 --> 00:02:21,480 One of the things that, you know, I found that was interesting in 54 00:02:21,480 --> 00:02:25,150 my research of this is that, well, actually, I'm not finding it fascinating, 55 00:02:25,150 --> 00:02:26,260 and I'm not surprised at all. 56 00:02:26,620 --> 00:02:30,430 People really shy away from this because they really hate managing constipation. 57 00:02:30,430 --> 00:02:31,720 They hate talking about it. 58 00:02:31,720 --> 00:02:35,200 They hate people showing them pictures on the phone of their poop. 59 00:02:35,420 --> 00:02:39,740 They hate the vague abdominal pain, and I think I'm constipated, which 60 00:02:39,740 --> 00:02:42,230 has so many different meanings for so many different people. 61 00:02:42,655 --> 00:02:46,135 Should we be reframing that how we think about constipation and how we think 62 00:02:46,135 --> 00:02:50,255 talking about bowel habits GI guys are good at it, but we see a lot of it too. 63 00:02:50,565 --> 00:02:54,075 Why is it important, Joe, to be good at diagnosing and treating constipation? 64 00:02:54,875 --> 00:02:54,995 Joe: Yeah. 65 00:02:54,995 --> 00:02:57,342 You know, for a long time I used to think that, I used to 66 00:02:57,342 --> 00:03:01,332 think, going to the bathroom's biology, it's not a medical thing. 67 00:03:01,887 --> 00:03:02,457 Tracey: Yeah, right. 68 00:03:02,502 --> 00:03:05,112 Joe: it's something your mom talks to you about, your grandmom talks to you about, 69 00:03:05,112 --> 00:03:07,822 and you could talk to anybody and they'll tell you what they do for constipation. 70 00:03:07,822 --> 00:03:09,802 It's like, why is this person coming to the urgent care? 71 00:03:09,802 --> 00:03:12,142 Why is this person coming to the ER with constipation? 72 00:03:12,142 --> 00:03:12,652 My God. 73 00:03:13,297 --> 00:03:13,807 Tracey: Eye roll. 74 00:03:14,412 --> 00:03:18,432 Joe: Yeah, I know, but you have to lean into it because they come and 75 00:03:18,432 --> 00:03:19,602 you gotta do something about it. 76 00:03:19,602 --> 00:03:24,042 And it's important because there are some complications of constipation that we have 77 00:03:24,042 --> 00:03:28,492 to be aware of and there's some mimics and like it or not, because these patients 78 00:03:28,492 --> 00:03:33,447 do come in, we have to, and this is not scientific, but it's just practical. 79 00:03:33,757 --> 00:03:36,847 And it kind of emerges from the branch points in the clinical pathway. 80 00:03:36,847 --> 00:03:41,512 It's not an initial three-pronged decision, but in the end we need to be 81 00:03:41,512 --> 00:03:45,322 able to put patients into one of three categories as far as constipation goes. 82 00:03:45,732 --> 00:03:49,932 There's that patient where they think constipation it's part of their chief 83 00:03:49,932 --> 00:03:52,872 complaint, let's say, but there's something a lot more going on. 84 00:03:52,872 --> 00:03:55,902 And somewhere during your h and p you start to get worried that 85 00:03:55,902 --> 00:03:57,552 it's just not simple constipation. 86 00:03:57,552 --> 00:04:01,632 There may be red flag symptoms or risk factors, multiple prior surgeries or bowel 87 00:04:01,632 --> 00:04:04,242 obstructions, let's say, or exam findings. 88 00:04:04,512 --> 00:04:09,297 And those patients are gonna be among the few ones in the ones that we see. 89 00:04:09,477 --> 00:04:11,577 But, you know, those patients are gonna go right to the ED. 90 00:04:11,577 --> 00:04:14,097 It's not gonna be, here's a laxative and then go home. 91 00:04:14,577 --> 00:04:17,797 Then, at the other end of the spectrum and, these are the ones I tend to 92 00:04:17,797 --> 00:04:20,974 see a little bit more in urgent care in the ED They're the people who are 93 00:04:20,974 --> 00:04:24,467 concerned 'cause they've had decrease in the frequency of their stool, but 94 00:04:24,467 --> 00:04:26,027 they're not in any really distress. 95 00:04:26,457 --> 00:04:29,787 You talk to them about things, they tell you that the stool's slowing down. 96 00:04:29,787 --> 00:04:32,517 They might have a little bit of gassiness or some distension, let's say, but 97 00:04:32,517 --> 00:04:34,287 no real abdominal pain or bleeding. 98 00:04:34,657 --> 00:04:38,117 And they may not have had that before and you are the one that's initially 99 00:04:38,117 --> 00:04:40,637 educating 'em because their mom and their grandma didn't do that. 100 00:04:41,027 --> 00:04:42,617 So a pretty straightforward approach for them. 101 00:04:42,617 --> 00:04:46,127 And usually, with a history and a belly exam that's benign, we need to be 102 00:04:46,127 --> 00:04:50,497 prepared for some recommendations about the stepwise use of stool, softeners, 103 00:04:50,497 --> 00:04:51,727 laxative, those kinds of things. 104 00:04:51,727 --> 00:04:53,977 If they haven't done that already, take them through. 105 00:04:54,777 --> 00:04:55,977 And then there's everything in between. 106 00:04:55,977 --> 00:04:57,777 And that's where we gotta put our thinking caps on. 107 00:04:58,147 --> 00:05:01,927 There's a complaint of constipation, at least it may be 108 00:05:01,927 --> 00:05:04,297 constipation plus something else. 109 00:05:04,347 --> 00:05:07,647 But there's enough discomfort that it's not sort of, Hey, here, just 110 00:05:07,647 --> 00:05:10,946 get some polyethylene glycol and follow the package instructions. 111 00:05:11,276 --> 00:05:14,656 We need to really sort through and make sure that they don't have a complication 112 00:05:14,656 --> 00:05:17,956 or a mimic, and that's where you're gonna be asking a lot more questions. 113 00:05:17,956 --> 00:05:21,376 Doing a more in-depth exam and doing that, rectal exam that we all love to do. 114 00:05:22,176 --> 00:05:23,219 Tracey: Yeah, I mean, I agree with you. 115 00:05:23,219 --> 00:05:25,717 You know, a Lot of people just want some guidance and I think 116 00:05:25,717 --> 00:05:29,017 it's sort of challenging trying to figure out who those people are that 117 00:05:29,017 --> 00:05:30,517 need a little more than just, go. 118 00:05:30,517 --> 00:05:32,707 To the laxative aisle and pick out A, B and C. 119 00:05:32,920 --> 00:05:34,831 It's funny 'cause I find a fair amount of people that have 120 00:05:34,970 --> 00:05:36,274 never tried one or two things. 121 00:05:36,274 --> 00:05:40,114 They either have tried everything that's in the GI aisle or they've 122 00:05:40,114 --> 00:05:43,054 tried absolutely nothing because they really didn't know where to start. 123 00:05:43,054 --> 00:05:44,638 There's kind of like no happy medium. 124 00:05:44,638 --> 00:05:46,875 It's either all Or Nothing which I think is pretty funny. 125 00:05:47,295 --> 00:05:47,745 Joe: Yeah. 126 00:05:47,815 --> 00:05:49,525 That's where education kind of Comes in, you know? 127 00:05:50,621 --> 00:05:52,751 Tracey: And the other thing that I find a fair amount of is there's 128 00:05:52,751 --> 00:05:55,421 a lot of clinicians out there that, are happy to hang their hat 129 00:05:55,421 --> 00:05:57,341 on constipation as a diagnosis. 130 00:05:57,341 --> 00:06:00,548 But The problem is there's a lot of those mimics, or a lot of things that 131 00:06:00,548 --> 00:06:04,388 are even not related to constipation, that have constipation as a symptom. 132 00:06:04,698 --> 00:06:08,208 I kind of urge people to, don't think of constipation as a diagnosis. 133 00:06:08,208 --> 00:06:09,483 Think of it as a symptom of something else. 134 00:06:10,091 --> 00:06:13,091 And once you've ruled out that there's nothing else going on there that you're 135 00:06:13,091 --> 00:06:17,168 really concerned about, then you can hang your hat on constipation and treat that. 136 00:06:17,168 --> 00:06:19,178 But then I also always give them the warning. 137 00:06:19,178 --> 00:06:22,715 You know, This may be constipation, like I said, it's a sign of other things. 138 00:06:22,955 --> 00:06:26,331 So if X, Y, and Z happens, please make sure that you Follow up in 139 00:06:26,331 --> 00:06:27,951 case something bad happens, right? 140 00:06:28,116 --> 00:06:32,616 So are there any myths that you busted when reviewing and rewriting this article? 141 00:06:32,616 --> 00:06:35,136 Kind of things that we've been thinking about or doing for years 142 00:06:35,136 --> 00:06:37,506 that are really just wrong and don't really have a benefit. 143 00:06:37,996 --> 00:06:38,236 Joe: Yeah. 144 00:06:38,266 --> 00:06:41,731 I think there are a few we, alluded to one of 'em and what we've already 145 00:06:41,731 --> 00:06:44,631 talked about, and that is that constipation is always benign and 146 00:06:44,631 --> 00:06:46,221 constipation is always constipation. 147 00:06:46,501 --> 00:06:49,621 There are important mimics that can lead to decreased bowel movements like. 148 00:06:49,771 --> 00:06:53,771 Obstruction some type of GI infections, diverticulitis, that kind of thing. 149 00:06:54,081 --> 00:06:57,711 But even if it's just constipation, there are some complications 150 00:06:57,711 --> 00:06:59,065 of it, like stercoral colitis 151 00:06:59,195 --> 00:07:02,045 , Or a full on, you know, fecal impaction that's not gonna get 152 00:07:02,045 --> 00:07:03,275 better with just a laxative. 153 00:07:03,275 --> 00:07:07,185 And we need to evaluate the patient for those and reliably exclude them. 154 00:07:07,573 --> 00:07:10,963 You can't really just take the patient's complaint of constipation at face 155 00:07:10,963 --> 00:07:14,683 value unless once you ask them more questions, it seems like their only 156 00:07:14,683 --> 00:07:17,563 complaint is a little bit of a decrease in their stool frequency and they're 157 00:07:17,563 --> 00:07:19,273 not otherwise having any problems. 158 00:07:19,813 --> 00:07:22,783 One of the other myths is the usefulness of x-rays. 159 00:07:22,783 --> 00:07:26,092 It's kind of intuitive, Hey, I should see a bunch of stool down there that should 160 00:07:26,332 --> 00:07:30,382 help me confirm the diagnosis and rule out other things like a bowel obstruction. 161 00:07:30,802 --> 00:07:34,252 But the fact of the matter is that they're not sensitive enough to 162 00:07:34,252 --> 00:07:35,812 rule out those important mimics. 163 00:07:35,872 --> 00:07:39,982 You may, if the patient has a bowel obstruction, see a bowel obstruction, 164 00:07:39,982 --> 00:07:43,652 but you can't really rule it out with x-rays that are not showing that A 165 00:07:43,652 --> 00:07:45,032 lot of times they're non-specific. 166 00:07:45,422 --> 00:07:49,727 The other side of that is that they don't always show constipation when 167 00:07:49,937 --> 00:07:52,007 the diagnosis may be constipation. 168 00:07:52,057 --> 00:07:56,254 There are a couple of cited studies in the article where, and particularly 169 00:07:56,254 --> 00:07:59,254 in pediatric patients, x-rays are done very frequently, particularly in 170 00:07:59,254 --> 00:08:01,234 the ED, they don't affect management. 171 00:08:01,714 --> 00:08:04,684 That the x-ray is done and there may or may not be constipation, 172 00:08:04,684 --> 00:08:07,324 but if it seems like history and exam suggests constipation, 173 00:08:07,324 --> 00:08:08,734 that's what the diagnosis was. 174 00:08:09,104 --> 00:08:13,261 And a lot of the ED physicians that were asked about why they got the 175 00:08:13,261 --> 00:08:17,797 X-rays, it was to get parental buy-in and is that a reason to do an x-ray? 176 00:08:18,267 --> 00:08:19,467 Tracey: That's crazy. 177 00:08:19,467 --> 00:08:22,817 You're radiating some poor kid just to buy in with the parents. 178 00:08:22,817 --> 00:08:24,381 That's, you know, I, I urge against that. 179 00:08:25,111 --> 00:08:26,221 Joe: Yeah, exactly. 180 00:08:26,221 --> 00:08:30,547 X-rays were the main thing that were available to us for so long and it's 181 00:08:30,547 --> 00:08:34,297 really, when you think about it, it's like you're looking inside the body, right? 182 00:08:34,627 --> 00:08:36,397 But you're really not looking inside the body. 183 00:08:36,497 --> 00:08:40,367 You're looking at shadows as you cast x-rays through the body and 184 00:08:40,417 --> 00:08:44,087 the real sensitivity for a lot of things is so poor we just shouldn't 185 00:08:44,087 --> 00:08:45,137 be doing 'em automatically. 186 00:08:46,087 --> 00:08:51,107 And then, maybe the third myth is the usefulness of docusate or we try to avoid 187 00:08:51,107 --> 00:08:53,027 brand names, but colace basically, right? 188 00:08:53,337 --> 00:08:57,522 This is probably in most people's minds, the stool softener that's the most 189 00:08:57,522 --> 00:09:01,306 commonly recommended, but most high quality studies show that it doesn't 190 00:09:01,306 --> 00:09:04,636 really do anything and there's certainly a lot of other better alternatives. 191 00:09:04,636 --> 00:09:07,746 So it probably should come off our list of recommendations for patients. 192 00:09:07,746 --> 00:09:09,096 It doesn't really soften the stool. 193 00:09:09,096 --> 00:09:10,446 It doesn't have a laxative effect. 194 00:09:10,686 --> 00:09:12,186 It's like not taking anything. 195 00:09:12,186 --> 00:09:12,456 So 196 00:09:12,826 --> 00:09:15,293 Tracey: I remember writing years of admitting orders for 197 00:09:15,293 --> 00:09:16,883 outta the ED or as a resident. 198 00:09:16,883 --> 00:09:20,388 You know, That's always on there with the acetaminophen and the antacid . And 199 00:09:20,388 --> 00:09:21,798 you gotta add the stool softener. 200 00:09:21,798 --> 00:09:23,938 'cause they're a hospitalized patient in bed. 201 00:09:23,938 --> 00:09:26,578 They're gonna get constipated, So make sure you give 'em the docusate. 202 00:09:26,638 --> 00:09:27,358 No. 203 00:09:27,358 --> 00:09:28,468 Doesn't work anymore. 204 00:09:28,743 --> 00:09:30,013 Joe: They may get constipated but the docusate's not gonna help. 205 00:09:30,183 --> 00:09:33,638 Hey, it works for ear wax though, it's a good, nice uh, cerumenolytic 206 00:09:34,248 --> 00:09:36,408 Tracey: Actually, there's also some studies that say it works pretty 207 00:09:36,408 --> 00:09:38,178 decent if you mix it into the enema. 208 00:09:38,658 --> 00:09:40,098 but orally not so much. 209 00:09:40,443 --> 00:09:40,866 Joe: Yeah. 210 00:09:40,866 --> 00:09:42,336 that little gel cap kind of thing. 211 00:09:42,336 --> 00:09:42,606 Yeah. 212 00:09:42,854 --> 00:09:45,544 Tracey: talking about the myths, the one thing that kind of freaked 213 00:09:45,544 --> 00:09:49,754 me out was the normal frequency of bowel movements is from three times 214 00:09:49,754 --> 00:09:51,794 per day to three times per week. 215 00:09:51,884 --> 00:09:54,974 What, like, how do you even answer that? 216 00:09:54,974 --> 00:09:56,794 That's like saying, it's either one or a million it's 217 00:09:56,794 --> 00:09:58,416 somewhere in there, that's nuts. 218 00:09:58,546 --> 00:10:01,089 I mean, How do you know if someone's constipated based on that? 219 00:10:01,139 --> 00:10:02,849 I remember getting it drilled into my head. 220 00:10:02,849 --> 00:10:04,199 You have to have a bowel movement every day. 221 00:10:04,199 --> 00:10:07,009 A normal bowel movement's once a day, from mom and auntie and 222 00:10:07,009 --> 00:10:08,749 grandma, did you have your BM today? 223 00:10:09,029 --> 00:10:11,600 So, not necessarily, true. 224 00:10:11,750 --> 00:10:14,450 You know, everybody has their own normal, I guess that's really the point. 225 00:10:14,450 --> 00:10:18,864 And, asking if somebody's constipated and they say yes you, gotta ask, well, 226 00:10:18,864 --> 00:10:22,747 on a good day when you're normal, what is your frequency of bowel movements? 227 00:10:22,747 --> 00:10:25,931 And that's how you decide if somebody's actually constipated or not. 228 00:10:25,931 --> 00:10:30,048 Because I know a lot of people Three times per week that would be agony for them. 229 00:10:30,378 --> 00:10:31,968 And a lot of people. 230 00:10:32,623 --> 00:10:34,183 If they don't go every single day. 231 00:10:34,183 --> 00:10:34,813 they're Yeah. 232 00:10:34,813 --> 00:10:35,563 they're in trouble. 233 00:10:35,563 --> 00:10:38,078 So you really have to flush that out when you take your history. 234 00:10:38,847 --> 00:10:38,907 Joe: Yeah. 235 00:10:39,077 --> 00:10:41,401 Well, I'll clear up a little bit of that if I can. 236 00:10:41,902 --> 00:10:46,116 There's the study in there where they developed the Bristol stool form scale. 237 00:10:46,366 --> 00:10:48,676 That was over 30 years ago in the United Kingdom. 238 00:10:48,676 --> 00:10:51,106 And you just gotta imagine diets were different. 239 00:10:51,106 --> 00:10:53,056 Bangers and mash and fish and chips and stuff. 240 00:10:53,056 --> 00:10:55,036 And so who knows what a normal stool frequency is in 241 00:10:55,036 --> 00:10:56,236 another country 30 years ago. 242 00:10:57,046 --> 00:10:57,346 Tracey: Yeah. 243 00:10:58,036 --> 00:11:02,136 Joe: But the three per day to three per week actually came from a study that 244 00:11:02,136 --> 00:11:05,316 was published in 2018, so relatively recently, was adults in the US. 245 00:11:05,316 --> 00:11:06,936 Most of our patients are from the US. 246 00:11:07,146 --> 00:11:13,156 Most of our listeners are from the US and it was NHANES data from 2009 to 2010. 247 00:11:13,156 --> 00:11:17,933 So a bit longer ago, but rather than using kind of the usual statistics, what 248 00:11:17,933 --> 00:11:25,350 they did was found a subset of patients almost 5,000 of them, 4,775, who felt that 249 00:11:25,350 --> 00:11:28,140 their stool frequency was quote, normal. 250 00:11:28,620 --> 00:11:32,400 And then they asked them how frequently they went, and it turned out that 95.9% 251 00:11:32,400 --> 00:11:35,435 of them went three to 21 times a week. 252 00:11:35,615 --> 00:11:37,025 So that's what they said. 253 00:11:37,025 --> 00:11:40,475 This, it's not really the statistics of finding a mean, and then two 254 00:11:40,475 --> 00:11:42,455 standard deviations is quote normal. 255 00:11:42,875 --> 00:11:44,285 And there's not a lot of other data. 256 00:11:44,345 --> 00:11:47,485 Interestingly enough, this study hasn't been cited by other studies. 257 00:11:47,485 --> 00:11:50,845 You can search stool frequency and there's not that statistical 258 00:11:50,905 --> 00:11:52,645 kind of basis as what's average. 259 00:11:53,145 --> 00:11:54,795 And then what's two standard deviations? 260 00:11:54,795 --> 00:11:56,055 We just don't have the information. 261 00:11:56,055 --> 00:11:59,895 So this is the best data we have, but not really, like statistically valid. 262 00:11:59,895 --> 00:12:03,585 96% of people who feel that their bowel movements are normal go 263 00:12:03,585 --> 00:12:05,475 between three and 21 times a week. 264 00:12:05,875 --> 00:12:08,362 like you said, when it's less than your own normal and you 265 00:12:08,362 --> 00:12:11,522 begin to feel uncomfortable that's the diagnosis of constipation, 266 00:12:11,739 --> 00:12:12,039 Tracey: Yep. 267 00:12:12,406 --> 00:12:14,176 All right, so let's go over some red flags. 268 00:12:14,222 --> 00:12:15,962 Most constipation, treat and treat. 269 00:12:15,962 --> 00:12:18,662 You know, You get a history, their belly's benign, no big deal. 270 00:12:18,662 --> 00:12:20,642 You give 'em some recommendations and bye-bye. 271 00:12:21,032 --> 00:12:22,532 What would make you think otherwise? 272 00:12:22,622 --> 00:12:26,042 And what are the disease processes or those mimics that you were talking about 273 00:12:26,322 --> 00:12:27,852 and which are the most serious of those? 274 00:12:28,652 --> 00:12:31,946 Joe: Yeah, well, you know, table four in the article has a nice sort of 275 00:12:31,946 --> 00:12:34,899 list of the, you know, as you're going through and asking your questions 276 00:12:34,899 --> 00:12:37,279 associated with the chief complaint. 277 00:12:37,279 --> 00:12:41,019 And then a review of systems like weight loss and cachexia and those kinds of 278 00:12:41,019 --> 00:12:44,592 things, and even family history of colon cancer can have a bearing, maybe not 279 00:12:44,592 --> 00:12:48,342 on your acute diagnosis but maybe other recommendations you're gonna make on 280 00:12:48,342 --> 00:12:49,812 the patient if they don't get better. 281 00:12:50,292 --> 00:12:53,982 You think about the fact that simple dehydration can slow somebody's stool 282 00:12:53,982 --> 00:12:56,952 down too, it's like, well, what if they're ill and they have dehydration 283 00:12:57,372 --> 00:13:00,192 and have a decrease in their bowel movements, as a result of that. 284 00:13:00,192 --> 00:13:03,172 So some of the red flag symptoms are fever. 285 00:13:03,587 --> 00:13:05,537 Nausea, vomiting, jaundice. 286 00:13:05,567 --> 00:13:07,277 Jaundice is bad no matter what. 287 00:13:07,617 --> 00:13:12,597 Bloody bowel movements or anemia on a CBC, I would say, severe rectal pain. 288 00:13:12,627 --> 00:13:15,397 And obviously, peritoneal signs or significant tenderness of 289 00:13:15,397 --> 00:13:17,227 a patient on abdominal exam. 290 00:13:17,627 --> 00:13:19,931 when you think that a lot of illnesses could be reflected 291 00:13:19,931 --> 00:13:21,238 in decreased bowel movements. 292 00:13:21,238 --> 00:13:23,668 You gotta step back and ask more questions. 293 00:13:23,668 --> 00:13:25,858 Could somebody with pneumonia have constipation? 294 00:13:25,858 --> 00:13:26,428 Well, yeah. 295 00:13:26,518 --> 00:13:28,948 And if you didn't ask about those symptoms or they didn't 296 00:13:28,948 --> 00:13:30,928 volunteer 'em, you might miss that. 297 00:13:31,378 --> 00:13:34,708 I think if you think about just the belly obstruction is probably the main thing 298 00:13:34,708 --> 00:13:38,638 that's gonna decrease somebody's bowel movements and be one of those mimics 299 00:13:38,638 --> 00:13:42,418 that's gonna be important not to miss, but also stuff like diverticulitis. 300 00:13:42,508 --> 00:13:46,258 A hernia causing an obstruction could uh, hopefully people would have pain 301 00:13:46,258 --> 00:13:49,488 or something else that would lead you down that diagnostic pathway. 302 00:13:49,488 --> 00:13:52,158 But sometimes you have to ask if a person's really fixated 303 00:13:52,158 --> 00:13:56,028 on the decreased frequency of stool, that may be all they say. 304 00:13:56,028 --> 00:13:58,338 And if you don't ask 'em any more questions or examine 'em really 305 00:13:58,338 --> 00:14:00,828 closely, you're gonna miss those things. 306 00:14:01,591 --> 00:14:03,211 Tracey: so maybe you know, fever, pain. 307 00:14:03,591 --> 00:14:04,281 Bleeding. 308 00:14:04,431 --> 00:14:05,061 vomiting. 309 00:14:05,521 --> 00:14:07,411 But you know, I mean, There can certainly be bleeding just from 310 00:14:07,411 --> 00:14:10,981 straining on hard stool, you know, the old rectal fissure or hemorrhoid. 311 00:14:11,085 --> 00:14:15,825 But, if it's truly bloody stool or, truly blood mixed in with the stool, that's 312 00:14:15,825 --> 00:14:19,125 way more serious than I saw a drops of blood on the toilet paper when I wiped. 313 00:14:19,673 --> 00:14:21,293 Joe: Heavy, heavy, heavy bleeding. 314 00:14:21,713 --> 00:14:24,353 And you know, that's sometimes hard to quantitate, but if it's 315 00:14:24,353 --> 00:14:26,663 almost like, Hey, that should be the person's chief complaint, 316 00:14:28,223 --> 00:14:29,183 should be their chief complaint. 317 00:14:29,738 --> 00:14:30,068 Tracey: Yeah. 318 00:14:30,248 --> 00:14:32,888 well, sometimes it is, you know, and then you ask a few more questions 319 00:14:32,888 --> 00:14:34,208 with that and they're like, oh Yeah. 320 00:14:34,208 --> 00:14:37,748 I've been pooping rabbit poo for three days, and now my belly's distended, 321 00:14:37,748 --> 00:14:39,199 And that's why my hiney's bleeding. 322 00:14:39,479 --> 00:14:41,626 So yeah, you gotta flush that out. 323 00:14:41,831 --> 00:14:44,821 Joe: What about vital sign abnormalities, tachycardia, hypotension, 324 00:14:44,821 --> 00:14:46,801 you know, lowest soft blood pressure, tachypnea. 325 00:14:48,361 --> 00:14:51,171 Those things are gonna tell you, you got a sick patient in any realm. 326 00:14:52,026 --> 00:14:53,691 Tracey: Hey, I do it with every single episode. 327 00:14:53,766 --> 00:14:55,176 So I'll just mention the vital signs. 328 00:14:55,176 --> 00:14:58,656 Again, you know, vital signs are so stinking important. 329 00:14:58,656 --> 00:15:01,746 you gotta look at those and you gotta explain 'em, you know, so if The 330 00:15:01,746 --> 00:15:05,598 person's tachycardic, hypotensive, obviously this is badness when you're 331 00:15:05,598 --> 00:15:08,928 talking about constipation, literally for every patient you see, if you 332 00:15:08,928 --> 00:15:12,508 see all of those, you really need to explain your abnormal vitals, 333 00:15:12,838 --> 00:15:13,438 and that's. 334 00:15:13,798 --> 00:15:15,662 One, you're gonna prevent that bounce back. 335 00:15:15,662 --> 00:15:17,548 You're gonna catch that more serious patient. 336 00:15:17,848 --> 00:15:21,348 And God forbid you should get sued, you know, if you miss those vitals 337 00:15:21,348 --> 00:15:23,868 and that's you're done, literally. 338 00:15:24,178 --> 00:15:26,458 Joe: It's, an objective measure that's sitting right there in the chart. 339 00:15:26,458 --> 00:15:29,868 You can always argue about, well, how tender was the patient's abdomen, but 340 00:15:29,868 --> 00:15:32,238 a heart rate of 1 22, it's right there. 341 00:15:32,328 --> 00:15:33,093 Tracey: you got it. 342 00:15:33,438 --> 00:15:33,978 You got it. 343 00:15:34,258 --> 00:15:36,568 You mentioned a few things that I think people will definitely 344 00:15:36,568 --> 00:15:38,098 not want to do in urgent care. 345 00:15:38,388 --> 00:15:41,508 One of the things was rectal exams on everyone with constipation. 346 00:15:41,508 --> 00:15:42,948 Do we really need to do that? 347 00:15:42,948 --> 00:15:44,358 Is that really necessary? 348 00:15:45,158 --> 00:15:46,768 Joe: No, I don't think so. 349 00:15:48,058 --> 00:15:50,808 you look in the clinical pathway, we altered the clinical pathway a little bit. 350 00:15:51,543 --> 00:15:54,363 On this from the ER issue to the urgent care issue. 351 00:15:54,813 --> 00:15:58,063 And if there's a concern about fecal impaction or if there's 352 00:15:58,423 --> 00:16:01,943 bleeding or a lot of rectal pain, then you gotta do the exam. 353 00:16:02,333 --> 00:16:06,223 But if it's that, second category of patient where they're really not in any 354 00:16:06,223 --> 00:16:08,573 discomfort, they don't have any bleeding and they're just telling you, you know, 355 00:16:08,573 --> 00:16:11,628 my my bowel movements are starting to slow down, and I'm a little bit bloated 356 00:16:11,628 --> 00:16:15,108 and I'm concerned, I would say that person doesn't need a rectal exam. 357 00:16:15,548 --> 00:16:18,578 And I would say somebody who's really sick and has peritoneal signs, don't 358 00:16:18,578 --> 00:16:22,053 worry about the rectal exam, if somebody's gonna pursue that at some point, but 359 00:16:22,053 --> 00:16:25,813 you already made your determination that the patient needs to go to the 360 00:16:25,813 --> 00:16:28,703 ED, why put them through a rectal exam? 361 00:16:29,003 --> 00:16:32,486 Really it's third group of patients where you're sorting and sifting and 362 00:16:32,486 --> 00:16:34,646 they're a little bit uncomfortable and maybe they had a little bit of 363 00:16:34,646 --> 00:16:38,046 blood on the toilet paper when you gotta kind of look down there and 364 00:16:38,046 --> 00:16:39,606 then also see if they're impacted. 365 00:16:39,886 --> 00:16:42,436 Also fissures, you know, that can be an important finding. 366 00:16:42,656 --> 00:16:46,886 It could be the result of constipation, hard stool passing through the anus. 367 00:16:46,956 --> 00:16:48,546 But it can also cause constipation. 368 00:16:48,546 --> 00:16:49,056 Sometimes people 369 00:16:49,056 --> 00:16:52,986 have so much pain if they have a fissure for some other reason and then they 370 00:16:52,986 --> 00:16:56,176 have discomfort with having a bowel movement, they'll actually not go. 371 00:16:56,176 --> 00:16:59,156 It could become constipated or develop a fecal impaction. 372 00:16:59,186 --> 00:17:01,496 'cause they're just, it's too uncomfortable to go and 373 00:17:01,496 --> 00:17:02,576 you gotta manage the fissure. 374 00:17:02,831 --> 00:17:05,261 And management of the fissure will help 'em quite a bit and it all 375 00:17:05,261 --> 00:17:08,058 contributes to the pain that makes it very difficult to get any farther. 376 00:17:08,644 --> 00:17:10,874 Tracey: Let's talk about enemas and disimpaction Uh, There is a 377 00:17:10,874 --> 00:17:14,208 section about that in the article about doing that in urgent care. 378 00:17:14,538 --> 00:17:18,288 Not really sure we can or should be doing those in urgent care. 379 00:17:18,288 --> 00:17:19,398 Have you ever done 'em in urgent care? 380 00:17:19,398 --> 00:17:21,928 I actually have I, used to work at an urgent care where it was 381 00:17:21,928 --> 00:17:26,728 run by a discovered or founded by an ED doc, and he was firm into 382 00:17:26,728 --> 00:17:27,838 keeping those people outta the ED. 383 00:17:28,018 --> 00:17:29,638 'cause my guess is he didn't wanna see 'em in the ED. 384 00:17:30,158 --> 00:17:32,888 So he went out and he bought the little bedside commodes and he 385 00:17:32,888 --> 00:17:34,738 bought the, soap suds enemas. 386 00:17:34,738 --> 00:17:39,028 And he made the poor nurses do enemas on, we had a lot of elderly patients do these 387 00:17:39,028 --> 00:17:41,608 in the clinic, stink up the whole place. 388 00:17:41,608 --> 00:17:42,148 It was awful. 389 00:17:42,148 --> 00:17:44,688 No patients even wanted to be in there when that happened, that 390 00:17:44,688 --> 00:17:47,538 was awkward, , but, it was a service we provided to some people. 391 00:17:47,538 --> 00:17:49,998 I'm not sure every urgent care is gonna wanna do that. 392 00:17:49,998 --> 00:17:50,688 What's your take? 393 00:17:51,488 --> 00:17:55,138 Joe: Yeah, I think you just have to decide whether you have the resources to 394 00:17:55,138 --> 00:17:59,458 do that and whether the other, clientele are gonna be maybe bothered by it. 395 00:17:59,588 --> 00:18:02,688 It's not that you can't but you may decide that it's just not appropriate 396 00:18:02,688 --> 00:18:05,724 for your venue but there's nothing about it that, you couldn't do. 397 00:18:06,524 --> 00:18:10,794 it's just sort of messy and difficult to think about and also if you're 398 00:18:10,794 --> 00:18:12,924 gonna do soap suds, I don't know if I would do soap suds just 'cause 399 00:18:12,924 --> 00:18:14,124 of the volume that's involved. 400 00:18:14,454 --> 00:18:19,809 But, you know, like A fleet enema or 133 ML enema, you can administer 401 00:18:19,809 --> 00:18:22,089 that in urgent care and make sure the patient's close to the 402 00:18:22,089 --> 00:18:23,739 bathroom or have a bedside commode. 403 00:18:24,079 --> 00:18:26,109 I do see some self selection. 404 00:18:26,139 --> 00:18:29,619 Seems like most of the patients that need that sort of thing do end up in the ED 405 00:18:29,649 --> 00:18:33,449 whether they come over from urgent care or just sort of self refer themselves there. 406 00:18:33,809 --> 00:18:37,123 And it's a kind of a group of patients who don't necessarily need that, 407 00:18:37,123 --> 00:18:40,573 who tend to come to urgent care, so you can help them with education 408 00:18:40,573 --> 00:18:42,883 more and ruling out the bad stuff. 409 00:18:43,133 --> 00:18:46,633 And it's never a fun thing, but being prepared, makes all the difference. 410 00:18:46,633 --> 00:18:50,113 If you're gonna do it, you gotta make sure, it's almost like PPE basically. 411 00:18:50,113 --> 00:18:51,583 You should have an impervious gown. 412 00:18:51,883 --> 00:18:54,913 You want to have eye protection, double glove, lots of lube. 413 00:18:55,093 --> 00:18:57,333 And I wear an N95 'cause this just. 414 00:18:57,913 --> 00:18:58,183 I don't know. 415 00:18:58,183 --> 00:19:00,913 There's something about the smell of that, you can even put some coffee 416 00:19:00,913 --> 00:19:05,623 grounds in it, N95 it, it can be kind of nauseating, the whole kind of process. 417 00:19:05,969 --> 00:19:09,959 I have found, I'll say it, it's uncomfortable for the patient. 418 00:19:10,059 --> 00:19:16,029 I have colleagues who don't stop until they like take 50% of the stool ball out. 419 00:19:16,829 --> 00:19:19,859 But I find sometimes just in the process of removing a little bit and 420 00:19:19,859 --> 00:19:23,679 softening it up, you can follow it with an enema and, it almost always works. 421 00:19:23,679 --> 00:19:25,709 It's just priming the pump almost 422 00:19:25,919 --> 00:19:28,989 I mean, If you have somebody with a huge stool ball, it's gonna be 423 00:19:28,989 --> 00:19:30,399 hard to do no matter what anyway. 424 00:19:31,179 --> 00:19:34,509 more than anything else, you're sort of softening it up, removing a little bit. 425 00:19:34,939 --> 00:19:38,599 Even, I'll use sometimes lidocaine gel and it kind of numbs up the, 426 00:19:38,649 --> 00:19:41,859 distal rectum in the anus a little bit so it's easier to pass stool. 427 00:19:42,659 --> 00:19:45,039 It's almost like removing a foreign body from an ear though, 428 00:19:45,039 --> 00:19:46,659 because it's hard to get above it. 429 00:19:46,969 --> 00:19:49,069 How do you get above this ball and pull it down? 430 00:19:49,069 --> 00:19:49,909 You're digging at it. 431 00:19:50,239 --> 00:19:54,539 They have these plastic corkscrew things that I've never used but I've 432 00:19:54,539 --> 00:19:58,349 seen advertised, which does kind of make some sense if you can screw 433 00:19:58,349 --> 00:20:01,579 it into the stool ball and sort of maybe deliver it like a baby. 434 00:20:02,379 --> 00:20:03,309 Tracey: like a bottle of wine, 435 00:20:03,804 --> 00:20:04,404 Joe: something like that 436 00:20:04,419 --> 00:20:05,229 Tracey: the bottle of wine. 437 00:20:05,629 --> 00:20:06,409 Joe: It's just it. 438 00:20:06,409 --> 00:20:08,749 I think it's just a difficult thing and it's one of those things 439 00:20:08,749 --> 00:20:11,293 where if you don't feel like you're set up to do, it takes time too. 440 00:20:11,323 --> 00:20:13,153 Which is another thing for urgent care. 441 00:20:13,153 --> 00:20:14,783 It's a procedure almost. 442 00:20:15,163 --> 00:20:18,298 Not only to do that, but then to administer the enema and 443 00:20:18,298 --> 00:20:19,918 wait for it to have some effect. 444 00:20:20,068 --> 00:20:21,418 And then dealing with the aftermath. 445 00:20:21,418 --> 00:20:24,458 So I wouldn't blame anybody for not wanting to do it in urgent care and, 446 00:20:24,458 --> 00:20:28,148 sending those people onto the ED, but , it's technically not difficult. 447 00:20:28,148 --> 00:20:29,748 So it could be done in urgent care. 448 00:20:30,478 --> 00:20:30,838 Tracey: Yeah. 449 00:20:30,838 --> 00:20:34,213 I think the average patients with constipation that we see in urgent 450 00:20:34,213 --> 00:20:37,141 care are gonna be in the mild to moderate category, and we're not 451 00:20:37,141 --> 00:20:39,977 gonna need to prove that they're fixed before we discharge them. 452 00:20:40,037 --> 00:20:42,907 And I'm sure they would be way more comfortable pooping in the, 453 00:20:42,907 --> 00:20:45,837 comfort of their own home rather than doing it in some bathroom. 454 00:20:45,837 --> 00:20:46,587 And that's the other thing. 455 00:20:46,587 --> 00:20:49,767 I mean, uh, We only have one toilet in the back with the patients. 456 00:20:49,957 --> 00:20:53,027 If it's, tied up with somebody who's evacuating what do we 457 00:20:53,027 --> 00:20:56,087 do for the urinalysis And the little kids that have to pee? 458 00:20:56,770 --> 00:20:58,180 that could definitely be a problem. 459 00:20:58,180 --> 00:21:00,183 So that might be a, a limiting factor too. 460 00:21:00,493 --> 00:21:01,603 Joe: it's a logistical, thing. 461 00:21:01,603 --> 00:21:03,993 I think more than a, a risky thing, let's say. 462 00:21:04,068 --> 00:21:04,488 Tracey: Yeah. 463 00:21:04,578 --> 00:21:04,938 Yeah. 464 00:21:05,388 --> 00:21:08,868 So I wanna talk about the dangers of diagnosing abdominal pain as constipation. 465 00:21:08,868 --> 00:21:10,068 I mentioned that a little bit, above. 466 00:21:10,093 --> 00:21:11,598 I, I never feel comfortable doing that. 467 00:21:11,598 --> 00:21:15,398 Most of the patients that I diagnose with constipation I better be pretty 468 00:21:15,398 --> 00:21:18,548 clear that they, you know, maybe they have some abdominal discomfort 469 00:21:18,548 --> 00:21:22,028 or some distension, but not true abdominal pain because I think. 470 00:21:22,078 --> 00:21:24,838 Even if you get that x-ray and you see , that stool on there or they 471 00:21:24,838 --> 00:21:27,598 tell you they're constipated or even if you feel it with your finger, 472 00:21:27,788 --> 00:21:31,638 like I said, constipation can be a symptom of some other disease process. 473 00:21:32,028 --> 00:21:34,888 How do you know when it's safe to call it just constipation, we talked 474 00:21:34,888 --> 00:21:37,498 about the red flags there, but let's just add a little bit more on that. 475 00:21:37,953 --> 00:21:38,223 Joe: Yeah. 476 00:21:38,223 --> 00:21:38,553 Yeah. 477 00:21:38,703 --> 00:21:42,183 Well, if you think about anything in the abdomen even like pancreatitis, 478 00:21:42,183 --> 00:21:46,213 which has nothing to do with the intestine or aaa, that's enlarging 479 00:21:46,423 --> 00:21:47,713 those things can cause an ileus. 480 00:21:48,448 --> 00:21:50,338 That can decrease a person's stool frequency. 481 00:21:50,338 --> 00:21:53,518 And if the person is focused on the decreased stool frequency, 482 00:21:53,998 --> 00:21:55,258 you can miss those other things. 483 00:21:55,258 --> 00:21:57,028 And most of the time those are gonna be painful. 484 00:21:57,278 --> 00:21:58,898 And that's where the abdominal pain comes in. 485 00:21:58,898 --> 00:22:00,488 I think the basis of your question, 486 00:22:00,828 --> 00:22:04,012 It's important to get at that in your history, what is the chief complaint? 487 00:22:04,012 --> 00:22:07,577 Is it only decreased bowel movements or decreased bowel movements plus 488 00:22:07,577 --> 00:22:10,427 belly pain, then you gotta ask all the belly pain questions, really. 489 00:22:10,427 --> 00:22:13,967 Or when you palpate the abdomen and there's anything more than mild 490 00:22:14,057 --> 00:22:18,563 tenderness or gassiness almost mild distension then, you really gotta ask 491 00:22:18,563 --> 00:22:21,923 a lot more questions and think about doing more in terms of your exam. 492 00:22:22,723 --> 00:22:25,363 If again, what's the patient's chief complaint and then as I'm 493 00:22:25,363 --> 00:22:27,993 sorting through in my mind, what should be the chief complaint? 494 00:22:27,993 --> 00:22:29,253 We've talked about that with the bleeding. 495 00:22:29,583 --> 00:22:31,667 It's like you're concerned about the constipation, but your abdomen 496 00:22:31,667 --> 00:22:35,683 is really tender and you have a lot of pain, so reframing what you're 497 00:22:35,683 --> 00:22:39,403 concerned about after that chief complaint is important and something 498 00:22:39,403 --> 00:22:41,693 else may rise to be more important. 499 00:22:41,813 --> 00:22:46,853 Things like vomiting tend to indicate that ileus or a GI infection or 500 00:22:46,853 --> 00:22:49,193 obstruction, fever of course. 501 00:22:49,343 --> 00:22:51,953 And then, if there's anything more than minimal pain, then you 502 00:22:51,953 --> 00:22:53,693 really gotta diagnose the pain. 503 00:22:54,118 --> 00:22:57,578 As well as the decreased stool frequency, I think. 504 00:22:57,878 --> 00:23:01,148 And to say that it's just constipation, I think you really 505 00:23:01,148 --> 00:23:02,738 have to do something about it. 506 00:23:02,738 --> 00:23:05,258 And that's where you're probably talking about an enema, having the 507 00:23:05,258 --> 00:23:10,608 patient have a bowel movement and then feel back to normal And like you 508 00:23:10,608 --> 00:23:13,641 said, sometimes it's safe to do that in the comfort of their own home. 509 00:23:13,821 --> 00:23:16,156 But that's Where you have to advise them and say, look, you got a 510 00:23:16,156 --> 00:23:17,836 little bit of abdominal discomfort. 511 00:23:17,866 --> 00:23:19,006 Your stool's decreased. 512 00:23:19,006 --> 00:23:21,286 It doesn't look like anything else going based on your answers 513 00:23:21,286 --> 00:23:23,566 to these questions and your exam. 514 00:23:23,896 --> 00:23:26,622 So do something to stimulate your bowels. 515 00:23:26,772 --> 00:23:29,352 And if you go and you feel back to normal, you're done. 516 00:23:29,652 --> 00:23:32,232 But if you don't feel back to normal or these other symptoms 517 00:23:32,232 --> 00:23:34,522 develop, then you need to be concerned about these other things. 518 00:23:34,522 --> 00:23:38,122 I remember, geez, probably within the past year or so, a young 519 00:23:38,122 --> 00:23:40,312 guy came in with constipation. 520 00:23:40,312 --> 00:23:44,742 That was his, chief complaint and it turned out he did have some pain, but 521 00:23:44,742 --> 00:23:46,032 he also had some decreased bone wounds. 522 00:23:46,062 --> 00:23:47,322 Never been constipated before. 523 00:23:47,322 --> 00:23:49,152 Had no reason to be constipated. 524 00:23:49,392 --> 00:23:53,472 Had some tenderness across his lower abdomen, but did not want any tests. 525 00:23:53,562 --> 00:23:54,942 Said, look, I talked to my mom. 526 00:23:55,692 --> 00:23:56,922 She said, I'm just constipated. 527 00:23:56,922 --> 00:23:58,592 I was like, well, I'm concerned you have this or that. 528 00:23:58,592 --> 00:24:01,832 And he said, no I'm constipated. 529 00:24:01,832 --> 00:24:02,162 What do I do? 530 00:24:02,162 --> 00:24:04,649 I said, what did your mom tell you to do anyway? 531 00:24:04,889 --> 00:24:07,269 I, had him get some polyethylene glycol. 532 00:24:07,269 --> 00:24:09,019 I think that tends to work pretty well. 533 00:24:09,019 --> 00:24:11,539 I see most of our GI people and our surgeons recommend that. 534 00:24:11,959 --> 00:24:14,779 And sure enough, two days later, he came back with right lower quadrant pain and 535 00:24:14,779 --> 00:24:18,439 had appendicitis, which probably was present right from the start, but he 536 00:24:18,439 --> 00:24:20,644 himself had to be convinced about that. 537 00:24:21,014 --> 00:24:23,834 He followed the precautions too and came back. 538 00:24:23,834 --> 00:24:27,384 And it wasn't a perforated API or anything like that, but I documented 539 00:24:27,384 --> 00:24:30,444 the heck out of that, that, this patient needs other tests but doesn't want them. 540 00:24:30,444 --> 00:24:34,284 And also the, discharge instructions I think were important for him to know. 541 00:24:34,284 --> 00:24:37,164 This isn't simple constipation because you went to the bathroom 542 00:24:37,524 --> 00:24:38,589 and you didn't feel any better. 543 00:24:39,184 --> 00:24:39,729 Tracey: Right, right. 544 00:24:39,779 --> 00:24:40,069 Joe: Yeah. 545 00:24:40,359 --> 00:24:40,869 Tracey: Exactly. 546 00:24:41,244 --> 00:24:41,574 Yeah. 547 00:24:41,994 --> 00:24:42,174 All right. 548 00:24:42,174 --> 00:24:43,824 So let's bottom line treatment real quick. 549 00:24:43,864 --> 00:24:45,004 Does one size fit all? 550 00:24:45,004 --> 00:24:47,254 Should you just have a go-to that you give to everybody? 551 00:24:47,704 --> 00:24:50,235 And then what do you do with the patient that says, I've tried everything 552 00:24:50,235 --> 00:24:51,435 in the store and nothing's working. 553 00:24:51,835 --> 00:24:52,145 What do you think? 554 00:24:52,814 --> 00:24:53,684 Joe: Oh my gosh. 555 00:24:53,834 --> 00:24:55,682 It's hard to deal with somebody who's done everything already. 556 00:24:56,422 --> 00:25:00,802 Anyway, but there are differences in the potency of the different 557 00:25:00,802 --> 00:25:01,462 things that are available. 558 00:25:01,462 --> 00:25:03,832 It's always gonna be the case that some things work better 559 00:25:03,832 --> 00:25:07,132 for some people than others, and that, that's just kind of biology. 560 00:25:07,132 --> 00:25:10,719 I think, for some people, acetaminophen works better for their headache than 561 00:25:10,719 --> 00:25:13,269 Ibuprofen does, and then for somebody else, that's gonna be the opposite. 562 00:25:13,719 --> 00:25:16,139 For a lot of those basic things, just the way it is. 563 00:25:16,289 --> 00:25:21,879 But we do know that in general for all comers stuff like fiber and stool 564 00:25:21,879 --> 00:25:27,329 softeners are the lowest intensity, the lowest level, and not super effective 565 00:25:27,329 --> 00:25:30,599 if somebody's already constipated, they're more like preventative things. 566 00:25:30,909 --> 00:25:33,819 Increasing fiber or, taking a stool softener might help if 567 00:25:33,819 --> 00:25:35,289 somebody's in the early stages. 568 00:25:35,679 --> 00:25:39,129 There are a variety of stimulant laxatives that are the next step up, 569 00:25:39,129 --> 00:25:42,399 the next more aggressive treatment and there are several to choose from. 570 00:25:42,799 --> 00:25:47,079 And you can pick your favorite one as that second line agent or, 571 00:25:47,359 --> 00:25:48,739 give the patient some options. 572 00:25:48,979 --> 00:25:53,665 They can be taken something like, ducalax can be taken from above or below. 573 00:25:54,045 --> 00:25:57,805 And I guess you have to be a little bit careful sometimes about doing 574 00:25:57,805 --> 00:26:00,305 something from above if somebody's already constipated because it, 575 00:26:00,305 --> 00:26:03,365 can be uncomfortable as it's starting to churn its way through. 576 00:26:03,729 --> 00:26:07,039 or particularly if it's a strong stimulant has a strong stimulant effect, it might 577 00:26:07,429 --> 00:26:11,359 maybe conceptually be a little bit better to put it down below and stimulate. 578 00:26:11,674 --> 00:26:13,414 Like, uh, do it in a suppository form. 579 00:26:13,750 --> 00:26:18,840 I think, in the issue, the data somewhat supports this, that polyethylene glycol, 580 00:26:18,990 --> 00:26:23,650 which comes in a variety of generic forms, but it's basically MiraLax, right? 581 00:26:24,030 --> 00:26:25,800 Is probably the most useful. 582 00:26:25,980 --> 00:26:31,260 And I think when you think about this I, I didn't talk about it in the issue so much, 583 00:26:31,520 --> 00:26:33,950 but it is what's used in a bowel prep. 584 00:26:34,725 --> 00:26:35,985 And you can do it one of two ways. 585 00:26:35,985 --> 00:26:41,399 The old bowel prep was you take a gallon of fluid, and about 400 grams 586 00:26:41,399 --> 00:26:48,328 of P E G . so the usual daily dose of glycol is 17 grams a cap full mixed 587 00:26:48,328 --> 00:26:51,388 in whatever beverage you want to use, and that'll help keep you regular. 588 00:26:51,688 --> 00:26:53,638 If you don't take it every day and you get constipated, it 589 00:26:53,638 --> 00:26:55,778 can help you get unconstipated. 590 00:26:56,298 --> 00:27:03,652 But here's A medication with a range of dosing from 17 grams to 400 grams 591 00:27:03,725 --> 00:27:04,240 , Tracey: Oh my gosh. 592 00:27:04,310 --> 00:27:05,225 Joe: just basically keep. 593 00:27:05,845 --> 00:27:10,785 Take a dose, take another dose, and you can do that either gently, progressively, 594 00:27:10,785 --> 00:27:16,495 or, I wouldn't recommend it that I actually have had GI doctors recommend 595 00:27:16,495 --> 00:27:19,945 to me when I call them about a really constipated patient, having them do 596 00:27:20,040 --> 00:27:24,280 a gallon of go lightly, basically, or a gallon of polyethylene glycol just 597 00:27:24,280 --> 00:27:26,230 gradually over a longer period of time. 598 00:27:26,590 --> 00:27:31,620 But the new bowel preps, cram a lot of polyethylene glycol into two doses. 599 00:27:31,650 --> 00:27:32,970 Basically, you take one. 600 00:27:33,443 --> 00:27:35,333 Uh, My, my colonoscopy, gosh, I don't know. 601 00:27:36,133 --> 00:27:40,118 A couple years ago, and it was two doses of polyethylene glycol, like a big dose 602 00:27:40,118 --> 00:27:43,338 followed by a little dose or a little dose followed by a big dose, I think. 603 00:27:43,338 --> 00:27:45,768 And it just, it can really, I wasn't constipated, but it 604 00:27:45,768 --> 00:27:46,658 can really clean you out.. 605 00:27:47,358 --> 00:27:50,328 I think there's a lot of benefit in that and having people step 606 00:27:50,328 --> 00:27:52,008 up the amount that they use. 607 00:27:52,068 --> 00:27:54,678 You have to maintain your fluid intake too with that though. 608 00:27:55,158 --> 00:27:56,778 And something in that range. 609 00:27:56,818 --> 00:27:58,888 So that's your answer to everything in the store. 610 00:27:59,248 --> 00:28:02,922 If the person has taken, everything in the store, tell 'em to take 611 00:28:03,097 --> 00:28:06,587 there are max doses for the stimulant, laxatives and, magnesium 612 00:28:06,587 --> 00:28:07,967 citrate, other things like that. 613 00:28:08,387 --> 00:28:12,087 But polyethylene glycol, you can really kind of increase over time and it could 614 00:28:12,087 --> 00:28:16,332 help there are prescription medicines That are available, but they're mostly 615 00:28:16,332 --> 00:28:19,032 for chronic constipation, there's not a lot of evidence that they help 616 00:28:19,032 --> 00:28:20,622 if somebody's acutely constipated. 617 00:28:20,982 --> 00:28:23,802 If somebody has multiple bouts of constipation that you would call 618 00:28:23,802 --> 00:28:27,072 chronic constipation, that's a medicine that might help them not 619 00:28:27,072 --> 00:28:28,542 get constipated as frequently. 620 00:28:28,822 --> 00:28:30,772 We don't really prescribe them in urgent care. 621 00:28:30,842 --> 00:28:33,992 I mentioned 'em in the issue because it's important for us to be familiar with them. 622 00:28:34,332 --> 00:28:37,002 I am seeing more primary care doctors prescribe those, though they used to 623 00:28:37,002 --> 00:28:39,572 be just in the realm of GI doctors. 624 00:28:39,572 --> 00:28:42,342 But now I see, people on them and say, oh, who's your GI doctor? 625 00:28:42,372 --> 00:28:43,182 Oh, I don't have a GI doctor. 626 00:28:43,182 --> 00:28:45,672 My regular, my primary care doctor prescribed it for me. 627 00:28:46,292 --> 00:28:50,222 And then finally, for opioid induced constipation, methyl naltrexone works 628 00:28:50,222 --> 00:28:53,657 really I haven't ever had to do that in urgent care, but that works really well. 629 00:28:54,027 --> 00:28:58,097 I've done that in the ED often for people with opioid induced constipation. 630 00:28:58,467 --> 00:29:01,557 Sometimes patients on hospice and other things like that where the constipation 631 00:29:01,557 --> 00:29:05,127 is really uncomfortable for them and it actually works really well. 632 00:29:05,907 --> 00:29:08,707 Tracey: My mother was a oncology nurse and she used to have people that were 633 00:29:08,707 --> 00:29:10,147 on chronic narcotics all the time. 634 00:29:10,347 --> 00:29:10,637 Joe: Yeah. 635 00:29:11,057 --> 00:29:14,057 Tracey: She used to call severe constipation in a 636 00:29:14,057 --> 00:29:15,827 cancer patient, obstipation, 637 00:29:16,217 --> 00:29:17,687 obstinate, constipation. 638 00:29:19,037 --> 00:29:21,887 But whenever I ever tell anybody else that word, nobody ever seems to have 639 00:29:21,887 --> 00:29:24,347 ever heard of it before, but I always thought it was a cool thing to say, 640 00:29:24,422 --> 00:29:24,832 Joe: Yeah. 641 00:29:24,862 --> 00:29:25,342 Yeah, 642 00:29:26,097 --> 00:29:28,287 Tracey: so, out of everything that you've discussed in the article, 643 00:29:28,287 --> 00:29:31,227 was there anything that you found surprising or didn't really know 644 00:29:31,227 --> 00:29:33,957 when you started that you thought, Hey, wow, I'm gonna remember that. 645 00:29:34,757 --> 00:29:35,237 Joe: well, you know, 646 00:29:35,315 --> 00:29:36,405 stercoral colitis. 647 00:29:36,405 --> 00:29:37,835 I keep wanting, say stercical. 648 00:29:38,305 --> 00:29:40,965 Anyway, I'm not really sure about this disease entity. 649 00:29:41,245 --> 00:29:44,662 I included it in there because it is written about, it was part of the 650 00:29:44,662 --> 00:29:46,792 initial emergency medicine issue. 651 00:29:47,092 --> 00:29:51,405 But this is something I hadn't heard of in the first 20 years of practice. 652 00:29:51,495 --> 00:29:55,408 And, you don't hear about it in urgent care, but sometimes a radiologist will 653 00:29:55,408 --> 00:30:00,652 call it on CT and I would have to say getting on the phone with GI specialists 654 00:30:00,652 --> 00:30:03,892 and surgeons and say, Hey, I have a patient here with fecal impaction and 655 00:30:03,892 --> 00:30:06,142 stercoral colitis, They don't really care. 656 00:30:07,045 --> 00:30:11,745 so it's not really maybe as bad as it could be. 657 00:30:12,025 --> 00:30:15,925 So I guess have to say I don't know what to do with this diagnosis. 658 00:30:16,065 --> 00:30:20,145 The issue, actually talks about sometimes using antibiotics and that it could be 659 00:30:20,145 --> 00:30:23,565 if the patient's sick and they have fever and a leukocytosis and that kind of thing. 660 00:30:23,715 --> 00:30:26,385 It could be from stercoral colitis, I guess. 661 00:30:26,785 --> 00:30:29,425 Or you gotta be sure that there's nothing else going on also. 662 00:30:29,765 --> 00:30:34,160 But I guess I'd have to say that's the thing that I still don't know about 663 00:30:34,340 --> 00:30:34,490 Tracey: Yeah. 664 00:30:34,580 --> 00:30:38,240 Joe: I didn't know about, and I still, I'm kind of unsure how to handle that. 665 00:30:38,570 --> 00:30:41,330 I think you gotta call it and call in your specialists because it's not 666 00:30:41,330 --> 00:30:42,680 something that I would dismiss, but 667 00:30:43,070 --> 00:30:44,780 I'm still kind of Unsure what to do with that. 668 00:30:45,580 --> 00:30:46,150 Tracey: Definitely. 669 00:30:46,360 --> 00:30:46,600 Yeah. 670 00:30:46,600 --> 00:30:49,847 One thing that I saw, I mean, it sounds ridiculous because this is such a, common 671 00:30:49,847 --> 00:30:53,447 thought was the frequency of, bowel movements that are considered normal. 672 00:30:53,723 --> 00:30:56,727 I mean, That was so surprising to me cause I know some people that 673 00:30:56,727 --> 00:30:59,357 go very frequently and some people that, that go less frequently 674 00:30:59,357 --> 00:31:03,371 . And I guess just putting it into words that normal is what is normal for 675 00:31:03,371 --> 00:31:08,191 you and not necessarily, any specific number that you have to go every day, 676 00:31:08,191 --> 00:31:11,651 like mom said, so I guess that was probably what was the most surprising 677 00:31:11,651 --> 00:31:13,151 to me out of everything in the article. 678 00:31:13,561 --> 00:31:14,101 Joe: Yeah. 679 00:31:14,151 --> 00:31:16,091 The consistency of the stool is important too. 680 00:31:16,091 --> 00:31:18,521 You know, is it soft or rabbit, turd small. 681 00:31:18,531 --> 00:31:21,531 And that's where the Bristol stool scale can come in. 682 00:31:21,981 --> 00:31:26,465 And so in addition to a decrease in frequency kind of a hardening and a 683 00:31:26,975 --> 00:31:30,415 getting smaller of the stool is also something that can show that impending 684 00:31:30,415 --> 00:31:32,090 constipation is around the corner. 685 00:31:32,490 --> 00:31:34,770 Tracey: So if you're only going every few days, but the softness 686 00:31:34,770 --> 00:31:38,640 of the stool is of normal for you, then, you're not constipated just 687 00:31:38,640 --> 00:31:40,020 'cause you missed a few times. 688 00:31:40,030 --> 00:31:42,790 If you're still going and it's still soft, it's not hard as a rock. 689 00:31:42,790 --> 00:31:44,110 It's probably not constipation. 690 00:31:44,516 --> 00:31:47,096 Some people are just so preoccupied with that, it's like, I didn't 691 00:31:47,096 --> 00:31:48,296 go to the bathroom today. 692 00:31:48,296 --> 00:31:49,646 Oh, okay. 693 00:31:49,646 --> 00:31:51,176 Like, do you have any other symptoms? 694 00:31:51,176 --> 00:31:52,526 Well, no, I didn't go this morning. 695 00:31:52,526 --> 00:31:52,826 I'm like. 696 00:31:53,471 --> 00:31:54,941 I dunno what to tell you, 697 00:31:55,638 --> 00:31:55,938 All right. 698 00:31:55,938 --> 00:31:57,618 Let's just talk about some bottom lines. 699 00:31:57,618 --> 00:32:00,198 Like, the big one, we've said it a couple times, is don't just 700 00:32:00,198 --> 00:32:01,998 diagnose constipation with x-rays. 701 00:32:01,998 --> 00:32:04,698 That's really low sensitivity, specificity. 702 00:32:04,978 --> 00:32:08,448 One of the things that I tell people when I'm teaching about this is that I 703 00:32:08,448 --> 00:32:12,888 guarantee you, if we x-rayed a hundred asymptomatic patients, 50% of them would 704 00:32:12,888 --> 00:32:16,068 look like they were constipated on x-ray and not really have any symptoms and 705 00:32:16,068 --> 00:32:19,338 not really be constipated because it all depends on when you see the poo. 706 00:32:19,338 --> 00:32:22,728 If I'm gonna x-ray somebody right before they have their morning bowel movement, 707 00:32:22,728 --> 00:32:24,108 you're gonna see lots of poo in there. 708 00:32:24,108 --> 00:32:25,488 But that doesn't mean they're constipated. 709 00:32:25,858 --> 00:32:28,288 So really don't hang your hat on that one. 710 00:32:28,318 --> 00:32:30,918 I think the radiologists have pretty much stopped calling 711 00:32:30,918 --> 00:32:32,418 constipation on plain films. 712 00:32:32,598 --> 00:32:32,928 Joe: Yep. 713 00:32:32,928 --> 00:32:34,398 Tracey: I think we probably should too. 714 00:32:34,698 --> 00:32:38,343 And, one of my other schticks is, you know, a lot of people will do a 715 00:32:38,343 --> 00:32:41,153 flat plate to see if the patient's constipated, what you're really looking 716 00:32:41,153 --> 00:32:45,383 for is not for stool volume, but for the complications of obstruction or dilated 717 00:32:45,383 --> 00:32:48,623 loops or, the large width of the colon. 718 00:32:48,826 --> 00:32:50,536 which you're really not gonna see on a flat plate. 719 00:32:50,536 --> 00:32:53,356 So if you are gonna order an x-ray, you probably need to order the whole 720 00:32:53,356 --> 00:32:57,226 series with a, upright or a lateral decubitus to really get the sense of that. 721 00:32:57,506 --> 00:33:02,100 But, bottom line sensitivity for constipation on a plain film is not good. 722 00:33:02,100 --> 00:33:06,010 So don't hang your hat on that again, we talked about ruling out other causes. 723 00:33:06,010 --> 00:33:08,500 Constipation is a symptom, not really as a diagnosis. 724 00:33:08,500 --> 00:33:11,590 Unless you've ruled out all those other things, you really shouldn't hang your 725 00:33:11,590 --> 00:33:13,420 hat on that constipation diagnosis. 726 00:33:13,450 --> 00:33:14,710 And then red flags. 727 00:33:14,710 --> 00:33:18,840 We talked about those red flags and if, you start seeing 3, 4, 5 red flags 728 00:33:18,840 --> 00:33:21,870 in one patient, that's your signal that, oh, we're in trouble here. 729 00:33:22,090 --> 00:33:25,210 That patient's probably gonna need not a plain film, but a CAT scan 730 00:33:25,460 --> 00:33:26,690 to figure out what's going on. 731 00:33:26,690 --> 00:33:28,065 That's our bottom line. 732 00:33:28,065 --> 00:33:28,905 Take home points then. 733 00:33:28,905 --> 00:33:29,820 Anything else you wanna add? 734 00:33:30,510 --> 00:33:34,150 Joe: Yeah, I'll tell you my, last most memorable constipation 735 00:33:34,480 --> 00:33:38,500 chief complaint that didn't have constipation was a 54-year-old guy 736 00:33:38,500 --> 00:33:43,240 who came in, in the ED, and he, it said chief complaint, constipation. 737 00:33:43,240 --> 00:33:44,550 So I said, Hey, what's going on? 738 00:33:44,550 --> 00:33:45,810 He goes, yeah I haven't gone in a couple days. 739 00:33:45,810 --> 00:33:46,620 I usually go every day. 740 00:33:47,250 --> 00:33:47,640 Okay. 741 00:33:48,030 --> 00:33:49,380 Did anything lead up to it? 742 00:33:49,380 --> 00:33:52,170 You know, All those questions, no red flags, and he had some 743 00:33:52,170 --> 00:33:55,310 left lower quadrant discomfort Discomfort that was intermittent. 744 00:33:55,310 --> 00:33:57,680 He said, not necessarily related to trying to go. 745 00:33:57,983 --> 00:34:02,123 he said he tried a number of laxatives and a suppository and nothing came out. 746 00:34:02,923 --> 00:34:06,113 And, he had a little, the tiniest bit of dysurea. 747 00:34:06,913 --> 00:34:10,873 So no tenderness on exam even though he had this left lower quadrant pain. 748 00:34:11,233 --> 00:34:14,500 Did a urinalysis and, he had like 25 to 50 red cells. 749 00:34:14,500 --> 00:34:15,900 It wasn't gross hematuria. 750 00:34:16,630 --> 00:34:21,067 And so I said, you know, this might be something urinary even a have 751 00:34:21,067 --> 00:34:22,087 you ever had kidney stones before? 752 00:34:22,243 --> 00:34:22,333 No. 753 00:34:22,443 --> 00:34:24,465 and the rectal exam, he had no stool in the vault. 754 00:34:24,885 --> 00:34:27,905 So I was like, well you're probably not going 'cause there's nothing there. 755 00:34:27,905 --> 00:34:29,465 Obviously I can't tell what's farther up. 756 00:34:29,765 --> 00:34:32,380 Anyway, ended up doing a a CT without contrast. 757 00:34:32,410 --> 00:34:34,780 He had no stool anywhere in his colon anyway. 758 00:34:35,095 --> 00:34:37,034 And he had a distal Ureteral stone. 759 00:34:37,174 --> 00:34:40,597 So sometimes Decreased stool frequency could be coincidental. 760 00:34:41,057 --> 00:34:41,347 Tracey: Yeah. 761 00:34:41,467 --> 00:34:44,047 Joe: if the person isn't really thinking about the other symptoms, 762 00:34:44,047 --> 00:34:45,757 they may just be focused on that. 763 00:34:45,757 --> 00:34:48,647 So then it's not constipation if it's just coincidental, 764 00:34:49,232 --> 00:34:49,532 Tracey: Right. 765 00:34:49,787 --> 00:34:52,247 Joe: that patient brought home to me. 766 00:34:52,677 --> 00:34:56,367 I mean, If he hadn't tried any laxatives and it didn't work, I probably would've 767 00:34:56,367 --> 00:34:58,711 said, well, why don't you just try a laxative and come back if it doesn't work? 768 00:34:58,931 --> 00:35:01,949 And the Interesting thing was he did not have very bad pain with the stone. 769 00:35:02,554 --> 00:35:02,844 Tracey: Yeah. 770 00:35:03,269 --> 00:35:06,659 Joe: And if he had severe pain, radiating to his flank again, that 771 00:35:06,659 --> 00:35:07,559 would've been his chief complaint. 772 00:35:07,994 --> 00:35:08,284 Tracey: Yeah. 773 00:35:08,309 --> 00:35:11,729 Joe: but it's these kind of one-offs that can get us in trouble sometimes 774 00:35:11,729 --> 00:35:13,739 if we don't ask all the questions. 775 00:35:13,739 --> 00:35:13,859 And 776 00:35:13,859 --> 00:35:16,299 it was that little bit of feeling like he had to remember. 777 00:35:16,569 --> 00:35:19,909 I feel like I have to go, but not a lot's coming out. 778 00:35:19,929 --> 00:35:23,119 And it's a little bit irritated on the urinary Side, so anyway. 779 00:35:23,884 --> 00:35:25,774 Tracey: My weirdest one actually turned out to be shingles, 780 00:35:26,419 --> 00:35:26,689 Joe: Oh. 781 00:35:27,094 --> 00:35:27,844 Tracey: which, Yeah. 782 00:35:27,974 --> 00:35:28,814 And it was a long time. 783 00:35:28,814 --> 00:35:32,174 The lady had pain for like three weeks before she finally broke out in the rash. 784 00:35:32,174 --> 00:35:32,774 It was crazy. 785 00:35:32,774 --> 00:35:36,914 She came in with left lower quadrant abdominal fullness and I'm constipated, 786 00:35:37,134 --> 00:35:40,819 so we really had no significant findings, nothing like that. 787 00:35:40,819 --> 00:35:43,369 I treated her with some laxatives, but I said, you know, you don't get better. 788 00:35:43,819 --> 00:35:47,179 She had a GI doctor for some other reason I think GERD or something. 789 00:35:47,179 --> 00:35:48,289 I said, call your GI guy. 790 00:35:48,289 --> 00:35:51,679 So she calls the GI guy 'cause she doesn't get better with the laxatives. 791 00:35:51,679 --> 00:35:53,899 The GI guy, CAT scans her, she's got nothing. 792 00:35:54,109 --> 00:35:55,499 He says, go see your GYN. 793 00:35:55,499 --> 00:35:56,799 She goes to see your GYN. 794 00:35:56,799 --> 00:35:58,219 Her GYN ultrasounds her. 795 00:35:58,219 --> 00:35:59,089 She's got nothing. 796 00:35:59,299 --> 00:36:03,109 She came back to me three times and on the third time I'm like, you know what? 797 00:36:03,469 --> 00:36:06,379 Let's get you all the way undressed just to see if there's anything, damn. 798 00:36:06,379 --> 00:36:07,459 Wasn't there a rash there? 799 00:36:07,709 --> 00:36:08,939 And it, that was it. 800 00:36:08,939 --> 00:36:12,089 And once her shingles was gone, her sensation of constipation went away. 801 00:36:12,419 --> 00:36:13,259 So Yeah. 802 00:36:13,259 --> 00:36:16,099 it can be anything, it really can be anything and you really have to be 803 00:36:16,099 --> 00:36:17,839 diligent about trying to figure it out. 804 00:36:17,839 --> 00:36:20,342 I mean, Granted, don't look for shingles if you have constipation, 805 00:36:20,342 --> 00:36:22,242 but anything is possible, right? 806 00:36:22,422 --> 00:36:23,382 Joe: Wow, that's wild. 807 00:36:23,802 --> 00:36:25,572 Medicine is just so interesting. 808 00:36:25,572 --> 00:36:26,082 Gosh. 809 00:36:26,217 --> 00:36:26,577 Tracey: is. 810 00:36:26,667 --> 00:36:27,177 It is. 811 00:36:27,957 --> 00:36:29,067 All right so much for poo. 812 00:36:29,067 --> 00:36:29,997 I think we're done with Poo. 813 00:36:30,307 --> 00:36:30,637 Joe: Good. 814 00:36:31,017 --> 00:36:31,117 Tracey: Yeah. 815 00:36:31,297 --> 00:36:31,747 thank God. 816 00:36:32,017 --> 00:36:32,157 Right. 817 00:36:33,057 --> 00:36:36,087 Next up, just in time for summer, we're gonna be talking about some marine 818 00:36:36,087 --> 00:36:37,977 injuries next, which is very interesting. 819 00:36:38,007 --> 00:36:41,450 I found some cool pictures are gonna be in the issue of all kinds of things. 820 00:36:41,500 --> 00:36:44,797 The gentleman who wrote it is very passionate about the subject and 821 00:36:44,847 --> 00:36:46,227 there's some really cool stuff in there. 822 00:36:46,287 --> 00:36:49,617 And then followed by weight loss meds, which, we didn't really talk about with 823 00:36:49,617 --> 00:36:53,003 the constipation here, but weight loss meds, I'm seeing a lot more constipation 824 00:36:53,003 --> 00:36:56,616 with the glp so we will talk about that a little bit more when we talk about weight 825 00:36:56,636 --> 00:36:58,256 loss meds, so stay tuned for that one. 826 00:36:58,696 --> 00:36:59,686 Joe: can be constipating. 827 00:36:59,686 --> 00:37:02,086 Actually, there's a great table in the issue, so 828 00:37:02,186 --> 00:37:03,356 Tracey: There is, you should go. 829 00:37:03,356 --> 00:37:04,046 check it out. 830 00:37:04,046 --> 00:37:04,976 Yep, exactly. 831 00:37:05,336 --> 00:37:05,666 All right. 832 00:37:05,666 --> 00:37:07,806 So thanks everybody for listening and happy. 833 00:37:08,201 --> 00:37:08,801 February. 834 00:37:08,981 --> 00:37:09,341 Yeah. 835 00:37:09,341 --> 00:37:10,361 Happy Valentine's Day. 836 00:37:10,361 --> 00:37:10,841 There we go. 837 00:37:11,291 --> 00:37:11,951 Joe: That's right. 838 00:37:12,581 --> 00:37:14,351 Tracey: I hope you're all doing something fun with your loved 839 00:37:14,351 --> 00:37:17,251 ones and we will see you in March. 840 00:37:17,851 --> 00:37:18,511 Joe: Thanks everyone. 841 00:37:18,511 --> 00:37:18,901 Take care. 842 00:37:18,931 --> 00:37:19,201 Tracey: Yep. 843 00:37:19,201 --> 00:37:19,501 Thanks. 844 00:37:19,501 --> 00:37:19,921 Take care. 845 00:37:19,981 --> 00:37:20,341 Bye-bye. 846 00:37:21,141 --> 00:37:21,361 Joe: Bye. 847 00:37:21,361 --> 00:37:24,521 Tracey: I want to thank everybody to listening to this month's evidence based 848 00:37:24,521 --> 00:37:28,922 urgentology podcast . Just a reminder that subscribers can go to ebmedicine.net 849 00:37:29,112 --> 00:37:32,662 and read the full issue if you want more information, if you haven't already, 850 00:37:33,561 --> 00:37:35,451 Joe: And if you're not a subscriber head to the site. 851 00:37:35,621 --> 00:37:38,391 That's ebmedicine.net to check out what they have. 852 00:37:38,714 --> 00:37:42,324 If you subscribe you'll get access to the article as well as future articles 853 00:37:42,344 --> 00:37:44,944 and the whole archive of all past issues. 854 00:37:45,398 --> 00:37:46,548 Tracey: Look forward to seeing you there.