NYU Medical Grand Rounds
Clinical Vignette
Animesh Jain
PGY3
9/27/2011
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• The patient is a 45 year old female with a
chief complaint of constipation that has been
present for several years.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•The patient reports nearly 20 years of
intermittent constipation as well as bloating
and abdominal cramping. She has been
diagnosed with irritable bowel syndrome
(IBS) – constipation predominant.
•She is presently managed on a regimen of
multiple stool softeners and laxatives. She
also takes golytely (miralax) as needed.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•On her present regimen, she reports having
small pellet like bowel movements with
mucus every 2 days and an occasional large
bowel movement every 3-4 days.
•There is a sensation of incomplete
evacuation.
•She sometimes feels abdominal cramping
and pain that typically improve with large
bowel movements.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
•She intermittently has small amounts of red
blood with bowel movements, especially
after straining. This occurs once every few
months.
•Previous colonoscopies have shown no
colonic pathology.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
•Irritable bowel syndrome (IBS)
•Gastroesophageal reflux disease (GERD)
•Asthma
•Fibromyalgia
•Major depressive disorder
•Post-traumatic stress disorder (PTSD)
•Trigeminal neuralgia
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History (continued)
•Past Surgical History:
•None
•Social History:
•Denies alcohol or drug use, former smoker
•Single, unemployed, lives with family
•Family History:
•Denies relevant family history
•Allergies:
•Aspirin, celecoxib, bactrim, trazodone, paroxetine,
duloxetine, doxepin, codeine
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History (continued)
•Medications:
•Docusate 100mg three times daily
•Polyethylene glycol (miralax) 17gm twice daily as
needed for constipation
•Sennosides (senna) 17.2mg, at bedtime for
constipation
•Metamucil twice daily
•Simethicone 80mg twice daily for bloating
•Nexium 40mg twice daily
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History (continued)
•Medications continued:
•Calcium carbonate 1.25gm three times daily
•Cholecalciferol 400units three times daily
•Lithium 300mg nightly
•Fluoxetine 20mg daily
•Fexofenadine 180mg daily
•Albuterol inhaled 2puffs, four times daily as
needed
•Ipratropium inhaled 2puffs four times daily
•Mometasone inhaled 220mcg twice daily
•Zafirlukast 20mg twice daily
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: middle aged female, appearing
stated age in no distress
•Vital Signs: T: 98.5 BP: 100/60 HR: 60
RR:18 and O2 sat: 99%
•Remainder of the physical exam was
normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC:
•hemoglobin 12.0 gm/dL (normal 11-16 gm/dL)
•hematocrit 35%
(normal 34-47%)
•remainder of CBC was within normal limits
•Basic Metabolic panel:
•within normal limits
•Hepatic panel:
•within normal limits
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Other Studies
•Colonoscopy (2002)
•single 3mm hyperplastic polyp
•left and right colon biopsies showed
normal colonic mucosa.
•Colonoscopy (2008)
•Normal colonoscopy
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
• The working diagnosis at this point was
chronic constipation due to constipation
predominant irritable bowel syndrome.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Course
• Gastroenterology Clinic
– Given the patient’s continued symptoms of
constipation, bloating and cramping, she was
started on lubiprostone (amitiza) 24mcg twice
daily. Prior medications including bowel regimen
were continued without changes.
• 2 month followup
– Patient reported significant improvement in
symptoms. She was having daily bowel
movements without blood or mucus in stool.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Chronic constipation due to irritable bowel
syndrome, with significant improvemet on
lubiprostone.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS