Constipation
Constipation is a condition characterized by infrequent, difficult, or incomplete evacuation of hard stools, typically defined as fewer than three bowel movements per week.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding | Probability |
|---|---|---|---|---|
| Probability Diagnosis | Functional constipation (low fibre/fluid, sedentary) | Rome IV criteria met, no red flags, dietary/lifestyle factors | 「你平時食幾多菜同飲幾多水？」 | ~35% |
| Drug-induced constipation | Temporal relationship with medication start | 「幾時開始食呢隻藥？便秘係之前定之後開始？」 | ~20% | |
| IBS-C | Recurrent abdominal pain ≥ 1 day/week × 3 months, related to defecation, altered stool form | 「肚痛同去大便有冇關係？去完有冇好啲？」 | ~15% | |
| Serious Not To Miss | Colorectal cancer | Age > 50, new-onset change in bowel habit, PR bleeding, weight loss, iron-deficiency anaemia | 「有冇屙血？有冇瘦咗？」(Rectal mass on PR) | ~2% |
| Intestinal obstruction | Absolute constipation (no flatus), colicky pain, distension, vomiting [1] | 「完全冇辦法去大便？放屁都冇？有冇嘔？」 | ~1% | |
| Cauda equina syndrome | Saddle anaesthesia, urinary retention, bilateral leg weakness | 「股間有冇痺？有冇屙唔到尿？」 | <1% | |
| Pitfalls | Hypothyroidism | Cold intolerance, fatigue, weight gain, bradycardia, dry skin | 「有冇怕凍、成日攰、肥咗？」(Check pulse, thyroid) | ~2% |
| Hypercalcaemia | "Stones, bones, groans, moans, thrones" [5] | 「有冇骨痛？成日口渴、多尿？」 | <1% | |
| Hypokalaemia | Muscle weakness, medications (diuretics), arrhythmia [6] | 「有冇手腳冇力？食緊去水丸？」 | <1% | |
| Masquerades | Drugs (opioids, CCB, anticholinergics, TCA) | Drug-disease interaction: anticholinergics/opioids/TCA worsen constipation [3] | 「食緊咩藥？」 | ~20% |
| Depression | Low mood, anhedonia, poor appetite, psychomotor retardation | 「最近有冇唔開心、冇心機做嘢？」 | ~10% | |
| Diabetes (autonomic neuropathy) | Known DM, gastroparesis, postural hypotension | 「有冇糖尿病？」 | ~2% | |
| Trying to Tell Me Something? | Fear of cancer / laxative dependence / psychosocial stress | Patient's real reason for attending today | 「其實你最擔心係咩？」 | ~10% |
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Greeting, rapport, open question | 「你好呀，我係醫生，請坐。今日咩嘢唔舒服呀？」(Hello, I'm the doctor, please sit. What's bothering you today?) | Warm opening; establishes rapport; interpersonal marks |
| 0:30–2:00 | HPI: symptom analysis – onset, duration, frequency, stool consistency (Bristol), blood/mucus, straining, incomplete evacuation, associated pain | 「幾耐冇去大便呀？」「大便硬唔硬？有冇血或者黏液？」「去完有冇覺得仲未去乾淨？」 | Core presenting complaint; completeness of HPI |
| 2:00–3:00 | Red flags & systems review – weight loss, rectal bleeding, tenesmus, abdominal mass, new-onset > 50y, FHx CA colon, neurological symptoms (leg weakness, urinary), thyroid symptoms | 「有冇瘦咗？有冇屙血？有冇腳軟或者痺？」 | Screens serious DDx; marks for safety |
| 3:00–4:00 | PMH, Drug Hx, Diet, Social Hx – DM, thyroid, depression; opioids, CCB, iron, anticholinergics; fibre/fluid intake; exercise; stress; pregnancy possibility if female | 「食緊咩藥呀？有冇食鈣片、止痛藥？平時飲幾多水、食菜多唔多？」 | Drug-induced constipation is a top masquerade; diet is modifiable |
| 4:00–5:00 | ICE + hidden agenda – Ideas, Concerns, Expectations | 「你自己覺得點解會便秘？」「最擔心係咩嘢？」「你嚟到想我幫你做啲咩？」 | Direct ICE marks on CRF; uncovers hidden agenda (e.g. fear of cancer) |
| 5:00–5:30 | Summarise & check understanding | 「等我總結返：你大概兩個禮拜冇正常去大便，有肚脹同要好用力，你最擔心係唔係有腸癌，啱唔啱？」 | Shows active listening; interpersonal marks |
| 5:30–6:00 | Safety-net & close | 「如果有突然肚痛、屙血、嘔、或者完全冇辦法去大便，一定要即刻返嚟睇。」「你仲有冇嘢想問？」 | Safe closure; empathy; patient-centred finish |
Uncovering the hidden agenda: The patient may present with constipation but actually came because they fear colorectal cancer (e.g. a relative was recently diagnosed), or they are distressed about dependence on laxatives, or they have medication side effects they haven't disclosed. Always ask 「其實今日嚟，有冇特別嘢擔心？」 (Is there something specific worrying you today?).
| Domain | English Question | Cantonese Question | Why It Matters | If Positive, Think Of |
|---|---|---|---|---|
| Onset & Duration | When did constipation start? Sudden or gradual? | 「幾時開始便秘？係突然定慢慢嚟？」 | Acute → obstruction/drug; chronic → functional/IBS-C | Acute: IO, drug. Chronic: IBS-C, slow transit |
| Frequency | How often do you open your bowels now? | 「而家幾耐先去一次大便？」 | Rome IV: < 3/week | Functional constipation, IBS-C |
| Consistency | Are stools hard, pellet-like? Use Bristol chart | 「大便硬唔硬？好似羊屎咁一粒粒？」 | Bristol 1-2 = constipation | IBS-C, dehydration |
| Straining / incomplete evacuation | Do you strain a lot? Feel you can't finish? | 「要好用力先去到？去完覺得仲未清？」 | Key Rome IV criteria | Functional constipation, rectal prolapse |
| Blood / mucus | Any blood on stool or toilet paper? | 「大便有冇血？廁紙有冇血？有冇黏液？」 | Red flag for CRC [1] | CRC, haemorrhoids, IBD |
| Weight loss | Have you lost weight unintentionally? | 「有冇瘦咗？冇刻意減肥但輕咗？」 | Red flag – feature against IBS [2] | CRC, thyroid, depression |
| Abdominal pain | Any tummy pain? Related to bowel movements? | 「有冇肚痛？去完大便好啲定差啲？」 | Pain related to defecation → IBS-C (Rome IV) | IBS-C, obstruction |
| Vomiting / distension | Any vomiting or bloating? | 「有冇嘔？個肚有冇脹大咗？」 | Cardinal features of IO: pain + distension + vomiting + absolute constipation [1] | Intestinal obstruction |
| Neurological | Any leg weakness, numbness, urinary problems? | 「對腳有冇冇力、痺？有冇小便問題？」 | Screens cauda equina / cord compression | Cauda equina syndrome, spinal lesion |
| Thyroid symptoms | Cold intolerance, fatigue, weight gain, dry skin? | 「有冇怕凍、成日攰、皮膚乾？」 | Hypothyroidism is a classic masquerade | Hypothyroidism |
| Drug history | What medications? Opioids, CCB, iron, antacids? | 「食緊咩藥？有冇食止痛藥、血壓藥、鐵丸？」 | Drug-induced constipation: anticholinergics, opioids, CCB, TCA [3] | Drug-induced constipation |
| Diet & fluid | How much water, fibre, fruit/veg daily? | 「一日飲幾多杯水？食唔食菜同生果？」 | Low fibre/fluid = most common modifiable cause | Functional constipation |
| Exercise / mobility | How much do you move around daily? | 「平時有冇做運動？行唔行到路？」 | Immobility → constipation esp. elderly | Immobility-related |
| Mood / stress | Feeling low, stressed, anxious? | 「最近心情點？有冇壓力？」 | Depression is a masquerade; psychosocial → IBS | Depression, IBS, somatisation |
| PMH | DM, thyroid problems, previous surgery? | 「有冇糖尿、甲狀腺問題？做過手術未？」 | DM autonomic neuropathy → constipation; post-op adhesions | DM neuropathy, hypothyroidism, adhesive obstruction |
| Family history | Any family member with bowel cancer or IBD? | 「屋企人有冇腸癌或者腸炎？」 | FHx CA colon / IBD → feature against IBS [2] | CRC, IBD |
| Pregnancy (if female of reproductive age) | Could you be pregnant? | 「有冇可能懷孕？」 | Constipation is common in pregnancy [4] | Pregnancy-related constipation |
| Functional impact | How does this affect your daily life? | 「便秘對你日常生活有咩影響？」 | Biopsychosocial impact for CRF | Functional impairment |
Case Report Form Answer Builder
- CC: Constipation for [duration]
- HPI high-yield points: Onset; duration; frequency (< 3/week); stool consistency (Bristol scale); straining; incomplete evacuation; associated symptoms (abdominal pain, bloating, blood, mucus, weight loss, vomiting); diet/fluid/exercise history; medication history; functional impact
- Examples: "Concerned about worsening constipation not responding to dietary change" / "Worried the constipation may indicate bowel cancer" / "Seeking medication review as new drug may have caused constipation"
- How to phrase: State the patient's own reason — why today, why now. Link to ICE.
| Example Wording | |
|---|---|
| Ideas | "Patient thinks constipation may be caused by not drinking enough water" / "Patient worries it could be bowel cancer because a colleague was recently diagnosed" |
| Concerns | "Worried about colon cancer" / "Afraid of becoming dependent on laxatives" |
| Expectations | "Wants a colonoscopy to rule out cancer" / "Wants dietary advice" / "Wants a laxative prescription" |
- Functional constipation (commonest in primary care): supported by Rome IV criteria fulfilled, no red flags, identifiable lifestyle/dietary factors, normal examination
- If pain predominant + chronic: IBS-C (Rome IV: recurrent abdominal pain ≥ 1 day/week for 3 months, related to defecation + change in stool frequency/form)
- If recent medication change: Drug-induced constipation
- Minimum supporting evidence: Duration > 3 months, < 3 bowel movements/week, hard stools (Bristol 1-2), no alarm features, no organic cause identified
| DDx | Key Discriminator |
|---|---|
| IBS-C (or Functional constipation if IBS-C is main Dx) | Predominant abdominal pain related to defecation, Rome IV criteria |
| Drug-induced constipation | Temporal link to medication (opioid, CCB, anticholinergic, iron) |
| Hypothyroidism | Cold intolerance, weight gain, fatigue, bradycardia, dry skin |
| (If elderly/red flags present) Colorectal cancer | New-onset change in bowel habit > 50y, PR bleeding, weight loss, iron-deficiency anaemia |
| Domain | Problem |
|---|---|
| Biological | Chronic constipation causing haemorrhoids / anal fissure / risk of faecal impaction |
| Psychological | Anxiety about possible bowel cancer; low mood / depression contributing to symptoms |
| Social/Functional | Reduced quality of life; embarrassment affecting social activities; occupational impact (e.g. sedentary job worsening constipation) |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Dx |
|---|---|---|---|
| Functional constipation | Palpable faecal mass in LIF / suprapubic region on abdominal palpation | Deep palpation of abdomen, especially LIF and suprapubic | Loaded colon suggests significant stool retention without obstruction |
| IBS-C | Mild abdominal tenderness along colon without mass or organomegaly; normal exam is expected | Abdominal palpation | IBS is a functional disorder – no structural abnormality on exam or investigations [2]; tenderness with normal exam supports functional Dx |
| Colorectal cancer | Palpable rectal mass on digital rectal examination (DRE) | DRE with patient in left lateral position | Low rectal tumours are palpable; confirms organic cause |
| Intestinal obstruction | Abdominal distension with high-pitched / tinkling bowel sounds [1] | Inspect abdomen; auscultate all quadrants | Distension + hyperactive sounds = mechanical obstruction |
| Hypothyroidism | Bradycardia, dry skin, delayed relaxation of ankle reflexes, goitre | Pulse, skin inspection, thyroid palpation, ankle jerk | Signs of systemic hypothyroidism as the cause of constipation |
| Drug-induced | No reliable physical sign in a brief FM station | Review medication list; temporally correlate | Best "exam clue" is the drug chart; no specific sign |
Must Not Miss Red Flags – Urgent Referral
- New-onset constipation > 50 years with change in bowel habit
- PR bleeding (especially dark blood mixed with stool)
- Unintentional weight loss
- Iron-deficiency anaemia
- Palpable abdominal or rectal mass
- Absolute constipation (no flatus) → suspect intestinal obstruction → urgent surgical referral
- Neurological signs (saddle anaesthesia, leg weakness, urinary retention) → suspect cauda equina → emergency MRI
Any of these → Do NOT diagnose IBS or functional constipation. Investigate first.
Top traps that lose marks:
- Diagnosing IBS-C without excluding red flags — IBS should NOT have: weight loss, rectal bleeding, onset in older patients, FHx CA colon/IBD, positive FOBT, anaemia, raised ESR [2]. Always screen before labelling functional.
- Forgetting drug history — Drug-induced constipation is the #1 masquerade. Anticholinergics, opioids, TCA all worsen constipation [3]. Ask about every medication including OTC and supplements.
- Not asking about pregnancy in a woman of reproductive age — constipation is common in pregnancy [4].
- Missing ICE — The patient may have come specifically because they fear cancer. If you don't ask, you lose easy marks AND miss the hidden agenda.
- Not doing a safety-net — Even if functional, advise return if red flags develop.
Shortest safe management/safety-net line:
「如果有肚痛加劇、屙血、嘔、或者完全放唔到屁，要即刻去急症室。我哋之後可以安排驗血同視乎情況做腸鏡。」
High Yield Summary
What to ASK: Onset/duration, frequency, consistency (Bristol), straining, blood, weight loss, abdominal pain related to defecation, all medications (esp. opioids/CCB/anticholinergics), diet/fluid/exercise, mood, neurological symptoms, pregnancy, FHx CRC, ICE.
What to WRITE on CRF: Functional constipation (or IBS-C) as most likely Dx; DDx = drug-induced, hypothyroidism, CRC (if red flags); Biopsychosocial = loaded colon ± haemorrhoids / anxiety about cancer / impact on daily life and social activities; Physical sign = faecal mass on abdominal palpation or rectal mass on DRE if CRC suspected.
What NOT to MISS: Red flags (bleeding, weight loss, new onset > 50y, neurological signs, absolute constipation) → never label functional until organic excluded. Drug-induced constipation (ask every patient). ICE — the hidden concern is often fear of cancer.
Active Recall - Family Medicine Clinical Test
[1] Lecture slides: GC 194. Intestinal obstruction colorectal cancer.pdf (p10 — clinical features of mechanical obstruction) [2] Senior notes: Block A - Chronic diarrhoea_ irritable bowel syndrome and inflammatory bowel disease.pdf (p22 — features against IBS; IBS subtypes) [3] AOS material: AOS - Geriatrics.pdf (p19 — drug-disease interactions: constipation with anticholinergics, opioids, TCA) [4] Lecture slides: CFB (OG01) Physiology of Pregnancy and Minor Ailments.pdf (p21 — constipation common in pregnancy) [5] Senior notes: Ryan Ho Chemical Path.pdf (p22 — hypercalcaemia: stones, bones, groans, moans, thrones) [6] Senior notes: Block A - Electrolyte and Acid-Base Disorders.pdf (p27 — hypokalaemia causing ileus and constipation)
Leg Pain
Leg pain is a symptom arising from musculoskeletal, vascular, neurological, or other causes, ranging from benign muscle cramps to limb-threatening conditions such as peripheral arterial disease or deep vein thrombosis.
Ear Pain
Ear pain (otalgia) is discomfort in or around the ear that may arise from primary ear pathology or be referred from adjacent structures such as the temporomandibular joint, pharynx, or cervical spine.