Download Case 2 - Student Version

Case 2 Complaints of Constipation during an Office Visit
2012
Setting: Outpatient office visit, patient accompanied by her daughter-in-law
Chief complaint: An 85 year old white woman comes to the office with a complaint of
“constipation for several months.”
History of Present Illness:
The patient has complained of hard stools every third day, dark brown, for several
months. She hasn’t noticed any change in caliber, but claims she is straining to
defecate and sometimes has streaks of blood around the stool. She hasn’t changed
her diet and has not been ill recently.
Question 1:
Which description can be formally considered “constipation“?
a. bowel movements every other day
b. bowel movements every third day
c. patient discomfort with defecation
d. bowel movements once a week
e. incomplete evacuation
f. all of the above
Question 2:
Could normal aging explain this patient’s constipation?
a yes
b no
Question 3:
What other elements of the history are important to the chief complaint? (check all that
apply)
a.
dietary content
b.
fluid intake
c.
activity
d.
denture use
e.
OTC medications and/or herbal use
f.
Other medical conditions
Past Medical History:
Hypertension – 10 years
Diabetes – 10 years
Bilateral cataract surgery – 2 and 3 years ago
Appendectomy – age 1
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Medications: She has no known allergies.
atenolol 50 mg daily
diltiazem CD 300 mg daily
nortriptyline 10 mg daily
donepezil 5 mg daily
glucotrol 5 mg daily
colace, calcium, multivitamins
Question 4:
Which medications could be contributing to her constipation? Check all that apply.
a.
atenolol
b.
diltiazem
c.
nortriptyline
d.
donepezil
e.
calcium
Review of Systems:
The patient notes significant fatigue with her usual activities. She eats and sleeps well.
Her daughter-in-law describes her as being “depressed” in that she does not do many
of the activities she used to enjoy, and as having memory problems. The patient says
she has “some mild memory problems.” This has been going on for several years, and
she has been treated with an antidepressant, nortriptyline, for two years, without any
apparent change. Her doctor just started her on donepezil.
Question 5:
Which diagnoses (apart from the adverse effects of the medications listed to treat them)
could be contributing to her “constipation”?
a.
diabetes mellitus
b.
depression
c.
dementia
d.
hypertension
e.
a, b, and c
f.
all of the above
Question 6:
Should alcoholism be considered in trying to explain this patient’s constipation,
cognition, and affect?
a. Yes
b. No
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Question 7:
Which other endocrinologic conditions could explain this patient’s constipation,
cognition and affect?
a.
hypothyroidism
b.
hyperthyroidism
c.
hyperparathyroidism
d.
a,b,and c
e.
a and c
f.
none of the above
Question 8:
The MMSE score is 19, below the cutoff for normal cognitive function. She admits to
having some memory problems. What does this score indicate? Check all that apply.
a.
She has “mild cognitive impairment” and does qualify for having dementia or
depression
b.
She has a cognitive impairment appropriate for age
c.
She has dementia which is diagnosed by the low MMSE (Minimental state
examination) score
d.
She may have dementia and further testing is needed
e.
She has depression which is causing the low MMSE score
f.
She may have depression and further evaluation is needed
Question 9:
What further testing would be appropriate at this time?
a.
CT or MRI of the brain
b.
TSH, VDRL, B12, folate
c.
Neuropsychological testing
d.
HIV, Lyme titer
e.
CSF examination
f.
a, b, and c
g.
All of the above
Review of Systems, continued:
The patient also describes having urinary incontinence four or five times a day and
night for five years, as “I know that I have to go, but I never get to the bathroom in time.”
She began the oxybutinin a year ago and has had some improvement. She denies
fecal incontinence.
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Question 10:
This history is most consistent with which type of urinary incontinence?
a.
transient incontinence
b.
urinary tract infection
c.
urge incontinence
d.
stress incontinence
e.
overflow incontinence
f.
none of the above
Question 11:
What should be done in addition to a history – a detailed description of episodes – and
a physical examination including a pelvic and neurologic exam, as part of the initial
evaluation of her urinary incontinence?
a. post-void residual
b. urinalysis
c. chemistries (electrolytes, BUN, glucose, creatinine)
d. urodynamic testing
e. a, b, c
f. all of the above
Social History:
The patient lives alone in an apartment. She is a widow and has two sons, one of
whom lives nearby. She has a high school education and was employed as a secretary
years ago. She denies smoking or drinking, now or in the past.
Physical Examination:
The patient is a thin, alert elderly woman appearing her stated age, in no distress. She
walked independently and was cooperative. BP 178/80 HR 60 RR 18, weight 126 lbs,
height 5 ft. 4 in. HEENT- edentulous, unremarkable; Thyroid - not palpable; Chest clear, breasts small without mass, heart - RRR w/o murmur; abdomen - soft, no mass,
normal tone, dark brown stool, guaiac negative; Ext. 1+ dependent edema.
Neurological examination alert, oriented x2, MMSE 21/30, cranial nerves intact, normal
tone, reflexes depressed (1+) throughout, no tremor, strength 4- throughout, sensory
slightly decreased to sharp and dull in lower legs, gait within normal limits.
Laboratory Data:
White Blood Cell count 6.0 with 78% polys, 14% lymphs, 3% monos, 5%eo
Hemoglobin/Hematocrit 10.1 (12.3 – 15.5 g/dl)/ 32 (36.0-45.0 %)
Mean Corpuscular Volume 96 (80-96 fl) Reticulocyte count 2.2%
Chemistries: Na 140 Cl 104 K 4.6 CO2 26 BUN 48 Cr 2.2 Glucose 186
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Question 12:
The anemia could be due to: (check all that apply)
a.
Normal aging
b.
iron deficiency
c.
anemia of chronic disease
d.
B12 or folate deficiency
e.
Myelodysplastic syndrome
f.
hypothyroidism
g.
all of the above
Laboratory Data, continued: In view of the constipation, it was critical to ensure that
the anemia was not due to iron deficiency caused by a colonic lesion. Laboratory
testing was done as the patient did not want to undergo a bone marrow aspiration
unless absolutely necessary.
Iron 52 (65-175)
Transferrin 235 (204-360)
TIBC 294 (250-410)
% saturation 18 (26-42) Ferritin 89 (10-150)
Question 13:
Can iron deficiency be sufficiently eliminated based upon the laboratory testing ?
a.
yes with 90% probability or so, so that the decision to do a bone marrow
aspiration can be forestalled for now
b.
no, a bone marrow biopsy is indicated
Additional Laboratory Data:
Liver function tests normal Calcium 9.4 mg/dl (normal) albumin 3.4 mg/dl
Vitamin B12 876 (normal) Serum folate 16 (normal)
Hgb A1C 5.9 (4.7-6.4) TSH 1.2 (normal)
Serum and urine protein electrophoresis - no monoclonal proteins
Questions 14:
What is the most likely cause of this patient’s anemia of chronic disease?
a.
normal aging
b.
renal failure
c.
occult infection
d.
occult tumor
e.
none of the above
f.
any of the above
History:
You inform the patient that her blood pressure is poorly controlled, her kidneys are
functioning very poorly and that she may need dialysis in the future. She tells you that
she knows all about that because her brother-in-law was on dialysis for years, and she
knows that she “doesn’t want to live like that, on machines.” She adds, “if it is my time
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to go, that’s it.” You ask her to complete a health care proxy form on which she notes
“no CPR, no dialysis, no feeding tubes” and appoints her son as proxy. A diuretic is
added to her medications and an appointment for two weeks later is made.
The Next Visit
One week later she is brought to the ED by her son. She is extremely confused,
agitated and short of breath. She has had urinary incontinence all week and a low
grade fever. Physical examination indicates fluid overload. Her urinalysis reveals
cloudy urine packed with white blood cells and bacteria. Her EKG shows short runs of
ventricular tachycardia. Laboratory data indicate an elevated potassium, and an
increase in the creatinine to 3.3. Acute renal failure superimposed on chronic renal
insufficiency is diagnosed. Medical treatment is begun, including antibiotics and
kayexalate, however the intern in the ED suggests that dialysis should be done to treat
the hyperkalemia as rhythm disturbance persists.
Upon hearing this, the son says that he is the health care proxy and states that he
wants his mother to undergo this treatment, commenting that his mother meant that
“she did not want chronic dialysis – not this one time which may be life-saving.” The
attending reads the proxy form and says that she should not be dialyzed according to
the patient’s wishes on the form.
Question 15:
Assuming that the physicians feel that dialysis is medically indicated, who should make
the decision about whether she should receive dialysis?
a.
b.
c.
d.
e.
f.
The patient should make this decision now, with advice from her son and
doctor
Her son should make this decision now, with advice from the doctors
The doctors should make this decision now
The decision is already directed by the proxy form and her prior
discussion of her wishes
The hospital administrator on call should decide
An emergency application should be made to the court to have a judge
decide
Question 16: What decision should be made? Should she receive dialysis acutely
(assuming it is medically indicated)?
a.
Under no circumstance should she be dialyzed, but she should receive
medical therapy to provide comfort
b.
Unless she actively refuses and does not cooperate, she should be dialyzed
initially (once or twice) to see if her mental status and dyspnea clear sufficiently
to allow her to make this decision. If she does not improve, dialysis should
be discontinued in accordance with her advance directive
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c.
Unless she refuses and does not cooperate, she should be dialyzed initially
(once or twice) to see if her mental status and dyspnea clear sufficiently to make
this decision; if she doesn’t clear, the decision should be re-evaluated by her son
d.
Unless she refuses and does not cooperate, she should receive dialysis for
as long as it is medically indicated as per the wishes of her proxy (which may be
chronic), unless she regains the ability to decide and wants to stop.
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