Download Case 2 Complaints of Constipation During an Office Visit

Case 2 Complaints of Constipation During an Office Visit
Author: Laurie G. Jacobs, MD, Professor of Clinical Medicine and Division Head, Albert
Einstein College of Medicine & Montefiore Medical Center.
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
Answer: f
Medically, constipation is often defined as a frequency of <3 bowel movements a week.
Patients, however, often define it as stools that are firm, too hard to expel, too small,
painful or associated with a sensation of incomplete evacuation. It is generally
considered a change from baseline function.
Question 2:
Could normal aging explain this patient’s constipation?
a yes
b no
Answer: b
There is no clear evidence that colonic motility declines with age in humans, but there is
an increase in self-reporting of constipation and use of laxatives with aging. This could
be partly due to decreases in fecal water content with aging.
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
Answer: all
Fiber intake is important in maintaining motility, but fluid intake is essential. A marked
decrease in physical activity can contribute to constipation. Despite being edentulous,
most individuals can chew most foods with or without dentures, however, a poorly fitting
denture can produce pain and limit intake. Over-the-counter medications and herbals
can influence appetite and have other adverse effects.
Past Medical History:
Hypertension – 10 years
Diabetes – 10 years
Bilateral cataract surgery – 2 and 3 years ago
Appendectomy – age 18
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
Answers: b,c,d,e
Some common medications which can cause constipation include:
Anticholanergics (oxybutinin)
Aluminum antacids, bismuth (Pepto bismol); calcium antacids and supplements
Anticonvulsants – phenytoin, carbamazepine, phenobarbital
Antidepressants – tricyclics
Antihistamines
Antilipemics – cholestyramine, colestipol
Antiparkinsonian drugs: bromocriptine, Sinemet, amantadine
Antipsychotics – haloperidol, risperidone
Antispasmotics – oxybutynin, opiate or barbiturates
Diuretics, Calcium channel blockers
Iron supplements
Laxative misuse and fiber without sufficient fluids
NSAIDS (nonsteroidal anti-inflammatory agents), Opiates, Phenothiazines
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
Answer: e
Constipation or diarrhea may occur with autonomic neuropathy, most commonly caused
by diabetes. Changes in bowel habits and constipation can accompany changes in diet
that may accompany depression, in addition to adverse effects of antidepressant
medications, particularly the anticholanergic tricyclics. Cognition is important as
patients with dementia may miss meals without awareness, or eat more often, and may
also have a change in diet. Emotional status, including anxiety and depression, both
affect appetite.
Question 6:
Should alcoholism be suspected in trying to explain this patient’s constipation,
cognition, and affect?
a. Yes
b. No
Answer: a
Yes, alcohol abuse can continue or begin in late life and should be considered here.
The older person is more likely to reach a higher blood alcohol level given the same
amount, and present with greater intoxication. Sustained use can produce cognitive
decline, and be associated with anxiety with withdrawal, and in some individuals, be
associated with depression. Constipation could be due to inadequate food and fluid
intake compounded by the diuretic effect of the alcohol.
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
Answer: a,c
Hypothyroidism identified by an elevated TSH level has been found to occur in 17.5%
of adults over age 75, with 0.5% overtly hypothyroid. They can present with fatigue
(68%), “mental slowness” (45%), constipation (33%), cold intolerance (35%),
depression (28%), dry skin (35%) and other signs and symptoms common in older
adults in general which makes consideration and laboratory testing critical.
Hyperthyroidism is often associated with diarrhea, rather than constipation, although
this symptom is more commonly identified in younger patients (18% of elderly vs. 43%
young). As many as half the cases of hyperparathyroidism are diagnosed in older
adults, and can also present with subtle signs and symptoms prevalent in old age so
that its identification may be a clinical challenge. Gastrointestinal signs and symptoms
include peptic ulcer disease, pancreatitis, and constipation. Hypercalcemia can cause
polyuria, nephrocalcinosis and nethrolithiasis. Hypertension is frequently associated
but a causal mechanism is unclear. In addition, memory loss, delirium, personality
changes or depression can be identified in older adults with hyperparathyroidism.
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
Answer: d, f
The MMSE is not a diagnostic test, and the diagnosis of dementia requires
demonstration of acquired cognitive decline in memory and at least one other cognitive
function (eg. language, visual spatial, executive) sufficient to affect daily life in an alert
person. She may have dementia and/or depression, but the score falls below that for
mild cognitive impairment. Further neuropsychological evaluation is needed.
Question 9:
What further testing should be done at this time?
a.
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
Answer: f
Although it remains controversial, imaging of the brain is often done to evaluate for
stroke and structural disease. The likelihood of detecting structural lesions is increased
with onset of symptoms before age 60, focal neurologic signs or symptoms, abrupt
onset or rapid decline, predisposing conditions. A detailed clinical interview and formal
neuropsychological testing can assist is separating the diagnosis of depression from
dementia. A CSF examination, HIV and lyme testing is more rarely undertaken due to
the low prevalence of these disorders causing subtle dementia in an 85 year old
woman, and only in circumstances suggestive of chronic infection (syphilis, lyme, etc),
metastatic disease or normal pressure hydrocephalus.
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.
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
Answer: c
Urinary incontinence can be present in about 30% of community-dwelling older women.
Although transient incontinence implies that it is not persistent, the underlying causes,
most of which are not due to genitourinary pathology, may reoccur. Examples include
polyuria from uncontrolled diabetes, recurrent urinary tract infections, etc. Established
incontinence includes urge incontinence or detrussor overactivity characterized by
involuntary bladder contractions either due to CNS disease or intrinsic to the bladder.
The history is that of an urgency to void rapidly followed by involuntary voiding.
Leakage is moderate to large, with a post-void residual of less than 50cc. Stress
incontinence is the second most common type and is usually the result of pelvic muscle
laxity and “urethral hypermobility.” The defect is in urethral support rather than
sphincter incompetence, and incontinence occurs with episodes of increased
abdominal pressure such as seen with coughing. Outlet obstruction is much more
common in older men. Leakage is more chronic and in small amounts.
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
Answer: e
An important first step is to identify those with overflow incontinence indicated by a high
post-void residual. These patients may have bladder outlet obstruction or an
underactive detrussor, and require further diagnostic testing by urodynamic studies to
be differentiated. The history and physical examination should provide a working
diagnosis. Urinalysis and chemistries assist in evaluating transient causes, contributing
factors and renal insufficiency from hydronephrosis. Urodynamic studies is useful in a
subset, but not all patients with established urinary incontinence.
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
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
Answer: b, c, d, e, f
Although anemia is more prevalent (5-51% depending on patient samples) as aging
proceeds, it cannot be assumed to be due to aging alone. The MCV is within the
normal range, categorizing this as a normocytic anemia, but it is at the upper limit of
normal, so that a macrocytic anemia could be invoked as well, or a mixed picture. The
reticulocyte count is often useful initially to direct further testing. Thus early iron
deficiency or anemia of chronic disease can be considered. Macrocytic causes would
include B12 and folate deficiency, myelodysplastic syndromes, hypothyroidism, liver
disease.
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
Answer: a
Iron stores are often assessed by measurement of the serum iron, total iron-binding
capacity (TIBC), transferrin saturation, and ferritin. An elevated TIBC is most often
found in iron deficiency, and low values may be found with anemia of chronic disease
and malnutrition. The transferrin saturation (serum iron x 100/TIBC) has a mean about
7% in iron deficiency, compared with a mean of about 15% in anemia of chronic
disease, and is between 20 – 45% in normal individuals. In studies of the elderly, the
serum ferritin have been found to be useful, with values less than 18g/L are
associated with a greater than 95% probability of iron deficiency, and values greater
than 100g/L associated with a probability of less than 10% of iron deficiency. It
appears that this patient has a low likelihood of iron deficiency. One may choose to do
a bone marrow to be more certain if this was the decision point regarding whether she
should have a colonoscopy to rule out a colonic malignancy. This is a circumstance in
which clinical decision-making, patient preference, and the sense of the need to be
certain must be weighed carefully by the physician, with the patient and her family. If
the colonoscopy were to be done anyway, then this data makes the likelihood of iron
deficiency low.
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
Answer: b
Normal aging does not produce anemia. Using the Cockroft-Gault formula,
Cr Clearance = (140 – age [years]) x ideal body weight (kg) x 0.85 if female
Serum creatinine x 72
the creatinine clearance is 17 ml/min consistent with renal failure. The cause is likely
due to diabetes with hypertension. Anemia is caused by underproduction of
erythropoietin. Although an occult tumor or infection is possible, there is apparently no
elevation in the acute phase reactants and the physical examination and laboratory
evaluation are within normal limits. It is however, unusual to have such a high normal
MCV with the anemia of renal failure. However, with normal liver function, B12, folate,
SPEP and UPEP, TSH, the only other major consideration is a myelodysplastic
syndrome. This would require a bone marrow biopsy for diagnosis with cytogenetics.
As it is not urgent to make this diagnosis as she is likely to be treated with
erythropoietin for anemia due to renal failure and no other specific treatment would
likely be given at this time.
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
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
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.
Answer: Question 15: b; Question 16 b
Decisional capacity is the ability of an individual to understand and process her general
medical condition; weigh the benefits, burdens and risks of the options; appreciate the
implications and consequences of her choices; and arrive at and communicate a
consistent decision. Capacity is decision specific and, especially in elderly patients,
may fluctuate over time.
Because the patient's current confusion and agitation have diminished her capacity, at
least temporarily, it is appropriate for the care team to turn to her appointed health care
proxy to make decisions on her behalf until she can make them for herself. Certainly
her prior wishes, articulated to her physician and in her advance directive, should be
accorded considerable weight because they are presumably the product of capable,
informed and voluntary decision making, The only reason to depart from her advance
directive is if it does not truly reflect her wishes or apply to her current situation.
In this case, her son is interpreting her instructions based on his knowledge of her
preferences and values. In light of her statement about her brother's chronic dialysis
and the likelihood that limited dialysis may improve her mental status to enable her to
engage in further discussion, it would be appropriate to honor her proxy's request for a
restricted trial of dialysis. If, however, her capacity does not improve and it appears
that dialysis will have to be ongoing, it would be important to honor her explicit refusal of
that therapeutic plan.