Tips on learning the nonpsych stuff (management of constipation, headache etc) for inpatient units?

[Freddie Mercury]

Hey everyone,

Residency has been amazing so far, learning a ton and having a lot of fun even though I am at a program with a lot of call. I am currently on inpatient, we have amazing teaching regarding psych pathology and psych medications, but the one thing I feel I am personally lacking in is how to manage the day to day stuff like constipation/diarrhea, general aches and pains, headache, etc. In med school this stuff was typically handled really quickly by the residents without much explanation, because we were focused more on "board relevant" stuff of which constipation management really isn't.

I feel like I've asked 5 different attendings/residents about how to manage constipation, and I got 6 different answers. Just give some colase and miralax, ok throw in some lactulose etc. I'd wager all of this works fine for the most part, but I was wondering if there were any guidelines, literature or maybe textbook chapters for this routine stuff. One targeted to Psychiatrists would be ideal if it exists.

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[FlowRate]

Does your institution have an uptodate subscription? I uptodate almost everything. If you want to be evidence based, use uptodate's recommendations. If you want to use your resident/attending's favorite medications, ask them.

Constipation: Senna (8.6 mg BID) and Sorbitol (30mL BID).
Headache, aches/pains: Ibuprofen (400mg QID? c food) and Acetaminophen (650mg QID).

You can get fancy from there and should avoid NSAIDs in people who are NPO / have other relevant contraindications.

 

[randomdoc1]

I uptodate almost everything as well, that's usually where I start. Also, does your program have good services from the library? The program I am graduating from has a strong affiliation with a medical school and the librarians are excellent. They are usually very good at directing people to where to look for practice guidelines, EBM searches, etc.

 

[lymphocyte]

Hey everyone,

Residency has been amazing so far, learning a ton and having a lot of fun even though I am at a program with a lot of call. I am currently on inpatient, we have amazing teaching regarding psych pathology and psych medications, but the one thing I feel I am personally lacking in is how to manage the day to day stuff like constipation/diarrhea, general aches and pains, headache, etc. In med school this stuff was typically handled really quickly by the residents without much explanation, because we were focused more on "board relevant" stuff of which constipation management really isn't.

I feel like I've asked 5 different attendings/residents about how to manage constipation, and I got 6 different answers. Just give some colase and miralax, ok throw in some lactulose etc. I'd wager all of this works fine for the most part, but I was wondering if there were any guidelines, literature or maybe textbook chapters for this routine stuff. One targeted to Psychiatrists would be ideal if it exists.

UCSF Hospitalist Handbook. Android or iPhone. It's amazing for basic management stuff. Better than the Mass Gen Handbook in this respect (which is too detailed for what you're after).

UpToDate for constipation? Really? The constipation might self-resolve by the time you finish reading the article. You don't need all the latest literature on "headache"--what a topic!--if you're just looking for quick, nitty-gritty evidence-based management.

 

[OldPsychDoc]

I have a progressive escalation plan: colace + miralax or psyllium; then senna or MOM; then dulcolax; then Mg citrate (or the ever popular--with nurses at least--prune juice/Mg citrate sparkling cocktail.) But I usually start by asking the patient "what usually works for you at home?" and proceed accordingly. Also, this is a good time to avail yourselves of your RN staff's years of expertise--they have seen it all before. It's not wrong to gently inquire "What would you suggest for this patient?"

 

[splik]

UpToDate for constipation? Really? The constipation might self-resolve by the time you finish reading the article. You don't need all the latest literature on "headache"--what a topic!--if you're just looking for quick, nitty-gritty evidence-based management.

you are in no position to belittle or demean someone who is asking a reasonable question or making such suggestions. the problem with psychiatry residents of you ask me is that they never look anything up, and the anti-intellectualism, lack of inquiry and curiosity that is endemic in psychiatry residency. We should absolutely be encouraging people to look things up in uptodate or elsewhere (which is not the latest literature on the topic but s nice concise summary of what to do for the busy clinician). medicine today isn't about what you know but knowing where to look... I strongly encourage residents to consult guidelines and resources like uptodate (which is what the residents on medicine consults will be doing if you consult them anyway).

that said I wouldn't recommend up to date for psychiatry (even though it was put together by the faculty where I went to residency) I just don't think it is as good for psych as. it is for medicine.

 

[F0nzie]

Ben Gay for pain. RN to apply to affected area QID PRN.


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[Armadillos]

Agree with uptodate or for the really common stuff just general googling.

Or could ask your attending...

 

[birchswing]

Does your institution have an uptodate subscription? I uptodate almost everything. If you want to be evidence based, use uptodate's recommendations. If you want to use your resident/attending's favorite medications, ask them.

Constipation: Senna (8.6 mg BID) and Sorbitol (30mL BID).mthfr b vitamins - Google Search
Headache, aches/pains: Ibuprofen (400mg QID? c food) and Acetaminophen (650mg QID).

You can get fancy from there and should avoid NSAIDs in people who are NPO / have other relevant contraindications.

I would normally not proffer treatment suggestions, but since we're talking about Googling answers, why not throw in my folk wisdom?

I would assume ibuprofen could be contraindicated for a great number of psychiatric patients, who might be on SSRIs or have other conditions like hypertension. I try to avoid it as much as possible but take one 400 mg ibuprofen in a rare blue moon since Tylenol is not that effective for me, but the reason I avoid it is in large part due to its greater risk for stomach bleeding when taken with Paxil (or other SSRIs as far as I know). If I take it, I take it with kefir and a Zantac as a prophylactic against ulceration. I believe the impact factor is about 6x greater risk of bleeding when taken with an SSRI. (I also have other risks such as being a CYP2C9 intermediate metabolizer, which increases the AUC of ibuprofen, along with high blood pressure.) For constipation, I personally prefer Colace or prune juice (which works due to sorbitol and possibly some of the magnesium present).

Curious—how do methylated B vitamins help with constipation?

EDIT: And for prune juice, I use about 5 oz of prune juice mixed with about 10 oz water. Cuts down on sugar intake and the whole point of the prune juice is to draw more water into the colon, so I figure the extra water helps anyway.

 

[lymphocyte]

you are in no position to belittle or demean someone who is asking a reasonable question or making such suggestions. the problem with psychiatry residents of you ask me is that they never look anything up, and the anti-intellectualism, lack of inquiry and curiosity that is endemic in psychiatry residency. We should absolutely be encouraging people to look things up in uptodate or elsewhere (which is not the latest literature on the topic but s nice concise summary of what to do for the busy clinician). medicine today isn't about what you know but knowing where to look... I strongly encourage residents to consult guidelines and resources like uptodate (which is what the residents on medicine consults will be doing if you consult them anyway).

that said I wouldn't recommend up to date for psychiatry (even though it was put together by the faculty where I went to residency) I just don't think it is as good for psych as. it is for medicine.

Very specifically @splik, OP was asking for something to remedy "lacking in [knowing] how to manage the day to day stuff like constipation/diarrhea."

UpToDate is great. Perhaps even Harrison's. But these resources seem unresponsive to the question asked. There was no intention to demean or belittle anyone.

I was using humour to make this point: there are a dozen UpToDate articles on constipation. Are we talking etiology? Investigation? Acute? Chronic? Pathophysiology? Prevention? Management? Management for which etiology? They mention interventions like colonic secretagogues and 5HT(4) receptor agonists. These are all helpful to read about (and even important in the psychiatric context--like for clozapine-induced constipation), but, on the wards, when one is needing a clear-cut answer for a first or second line treatment for a common problem, plowing through these articles takes time. Now compound that across the range of common problems.

Again, UpToDate is a great resource. But I challenge the statement that it always has a "nice concise summary" of "what to do"--as if such a thing were possible. For example, for constipation, their summary section "for the busy clinician" includes a definition, a list of primary colorectal dysfunction syndromes, a suggestion for dietary and lifestyle modification--all before discussing first-line treatment for what most commonly occurs on the wards. "Docusate" isn't even mentioned in the primary article until you look at the corresponding table, which merely lists it as one of many options.

I get off and on the UpToDate bandwagon. It has lots of good stuff, but it sometimes might give you just as many opinions as those 5 different attendings/residents.

 

[notdeadyet]

Also, this is a good time to avail yourselves of your RN staff's years of expertise--they have seen it all before. It's not wrong to gently inquire "What would you suggest for this patient?"

Ah, yes. In intern year, I'm pretty sure the most common reply I gave to nurses was "Uhhhh... What do other doctors order for ________?"

 

[nancysinatra]

the problem with psychiatry residents of you ask me is that they never look anything up, and the anti-intellectualism, lack of inquiry and curiosity that is endemic in psychiatry residency. ... I strongly encourage residents to consult guidelines and resources like uptodate (which is what the residents on medicine consults will be doing if you consult them anyway).

A few months ago I posted something on this forum about how psychiatry residents never look stuff up or read, and I got hammered for it, and accused of making offensive generalizations. But apparently I'm not the only one ever to have said such a thing.

 

[nancysinatra]

Ah, yes. In intern year, I'm pretty sure the most common reply I gave to nurses was "Uhhhh... What do other doctors order for ________?"

I just ask the nurses directly! I value their knowledge so much. Sometimes we disagree but on routine things like constipation, they know their stuff. Pharmacy is another good source.

 

[Crayola227]

UCSF Hospitalist Handbook. Android or iPhone. It's amazing for basic management stuff. Better than the Mass Gen Handbook in this respect (which is too detailed for what you're after).

UpToDate for constipation? Really? The constipation might self-resolve by the time you finish reading the article. You don't need all the latest literature on "headache"--what a topic!--if you're just looking for quick, nitty-gritty evidence-based management.

No, this, never. It will "resolve" when they get so constipated that on top of their COPD, sleep apnea, they have restricted inspiration from their obese belly now filling with poo, need to get vented, and then can't get weaned for a week while you hope to God that OG tubing down as much bowel prep as you can with a rectal tube in will eventually clear enough poop to let you get them off the vent, but in the meantime, they get VAP and then die. I've seen this exact scenario except we got lucky that we were able to get them off the vent before the last two things could happen. Thank God. Nearly lost a patient to lack of bowel reg and constipation. Can you imagine???

Intern mega post the first link says making sure EVERY single patient has written in protocol driven bowel regimen is the next important thing you can do next to to their primary problems. That and their skin. Not pooping and skin breakdown!!!!! You can avoid so many delayed d/c's and extra hospital days if you fight this battle to win from HD #1.

http://www.lhsc.on.ca/Health_Professionals/LRCP/Oncology_Practice_Guidelines/Constipation.pdf

Is pretty close to what I do. You can write your bowel prep to be nurse protocol driven. Mine is a little different in that my 3rd step is Miralax.

Docusate BID, hold for loose stool, if no BM -->
Senna up to BID, hold for loose stool, if no BM -->
Miralax up to BID, hold for loose stool, if no BM --> at this point nurse should page you. You need to assess what to do next. Think about volume status. They might not look dry but need more fluids to poop. Try to get more in them if you can

The reason is that #1 docusate will make poop soft, easy to take. Senna is #2 because it can cause cramping. Miralax is #3 cuz it's gross to drink.

 

[lymphocyte]

No, this, never. It will "resolve" when they get so constipated that on top of their COPD, sleep apnea, they have restricted inspiration from their obese belly now filling with poo, need to get vented, and then can't get weaned for a week while you hope to God that OG tubing down as much bowel prep as you can with a rectal tube in will eventually clear enough poop to let you get them off the vent, but in the meantime, they get VAP and then die. I've seen this exact scenario except we got lucky that we were able to get them off the vent before the last two things could happen. Thank God. Nearly lost a patient to lack of bowel reg and constipation. Can you imagine???

It was a joke. A joke. About how unhelpful UpToDate can sometimes be. I'll just show myself out...

 

[Crayola227]

It was a joke. A joke. About how unhelpful UpToDate can sometimes be. I'll just show myself out...

I gotcha. Sorry. You just touched on one of my "clinical pearl passions." You'll never find another doc more on top of her **** than me.

 

[Crayola227]

nah really though it was crazy to see that person's course go all to hell over ****ing bowel reg

lesson learned early on

 

[Salpingo]

Hey everyone,

Residency has been amazing so far, learning a ton and having a lot of fun even though I am at a program with a lot of call. I am currently on inpatient, we have amazing teaching regarding psych pathology and psych medications, but the one thing I feel I am personally lacking in is how to manage the day to day stuff like constipation/diarrhea, general aches and pains, headache, etc. In med school this stuff was typically handled really quickly by the residents without much explanation, because we were focused more on "board relevant" stuff of which constipation management really isn't.

I feel like I've asked 5 different attendings/residents about how to manage constipation, and I got 6 different answers. Just give some colase and miralax, ok throw in some lactulose etc. I'd wager all of this works fine for the most part, but I was wondering if there were any guidelines, literature or maybe textbook chapters for this routine stuff. One targeted to Psychiatrists would be ideal if it exists.

I'd recommend a good palliative care elective, they touch on a lot of comfort issues and its good psych exposure.

 

[MLT2MT2DO]

Please don't give lactulose for simple constipation

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[Crayola227]

Please don't give lactulose for simple constipation

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I agree. You can use miralax and if not ESRD milk of mag.

 

[milesed]

ask a drug rep to buy you The Five Minute Clinical Consult book.

 

[FlowRate]

Docusate" isn't even mentioned in the primary article until you look at the corresponding table, which merely lists it as one of many options.

It's mentioned in the treatment article as an ineffective treatment lacking in evidence base.

You have to learn how to use uptodate. Find the article you're looking for (adult -> constipation -> prognosis, management, etc.) then skim to find the exact thing you're looking for (management -> first line agents).

You can use something more "distilled" at the expense of having a nuanced understanding of why it's recommending one treatment over another.

I'd recommend reading the uptodate article on constipation. IIRC, it clearly lays out that sorbitol and lactulose are more effective than miralax, sorbitol being better the better tolerated and faster acting alternative, colace is useless, and senna is probably the go-to first line.

 

[Amygdarya]

UCSF Hospitalist Handbook mentioned above is awesomely practical for run of the mill medical complaints. I have just discovered - and couldn't resist sharing it here - that you can either buy an up to date version of it for $20 (https://www.agilemd.com/library/add/hospitalist) or get an older version online for free (http://66.199.228.237/hosptialist/medicine.ucsf.edu/education/resed/handbook/#TOC). Interestingly the updated version doesn't have info on constipation while the older version does.