Case Study # 2

Chief Complaint: Constipation

History and Present Illness:

Marie, A 58-year-old woman with a complicated history which includes chronic low back pain, bipolar disorder, mixed anxiety, and depressive disorder presents to her PCP, a PA, complaining of constipation for several months. She reports her constipation has been intermittent and become progressively worse over the past few weeks. Currently, she reports her bowel movements occurring about once every 4 days; she describes her stools as hard and painful and she occasionally notes bright red blood on the toilet paper after she wipes. She does not feel she successful in completely evacuating her bowels. She denies melena, abdominal pain, bloating or excessive gas, loose stools, or fecal incontinence. She admits she is fearful of taking medications and has not tried any over-the-counter treatments for fear of side effects. She denies any changes in her regular medications and no short-acting narcotics for breakthrough pain. She endorses a regular diet (lean protein, fruits/vegetables, grains) without changes; she does however admit to poor water intake, about 20 ounces daily; she denies caffeine or alcohol use. She confirms her stress level has not increased; she admits to daily anxiety that limits her activities but reports she feels her anxiety is at baseline. She denies ever having had a colonoscopy due to anxiety about the procedure and potential outcomes. She reports that her chronic low back pain has been stable for the past 6 years on her current medication regimen; she has been on the same dose of extended-release morphine sulfate for the past 4 years. She fears discontinuing morphine sulfate will result in an exacerbation of her back pain. She denies exercising, attending physical therapy or being followed by a pain management specialist.

Review of Systems:

Marie’s ROS is positive for constipation, bright red blood per rectum, and anxiety. The ROS is negative for fever, night sweats, weight changes, fatigue; hair or skin changes, heat, or cold intolerance; and belching, halitosis, heartburn, early satiety, nausea, or vomiting. Other ROS includes: negative for chest pain, palpitations, SOB, mania, ideas of grandiosity, hallucinations, suicidal ideations, and worsening anxiety or panic.

** List what other ROS details you would want to know in the discussion**

Relevant Medical, Surgical and Family History:

The patient’s medical history is significant for asthma (since childhood), bipolar disorder (age 25), mixed anxiety and depressive disorder (age 45), GERD (age 50), hyperlipidemia (age 52), hypothyroidism secondary to lithium use (age 42; TSH last checked 3 months ago, in normal range), IBS-C, (age 48), chronic low back pain (age 52), psoriasis (age 23), diverticulitis (last episode 2 years ago, diet controlled), and primary hyperparathyroidism with hypercalcemia post partial resection 15 months ago (serum calcium level in normal range 3 months ago). Her social history includes no use of alcohol, tobacco, or recreational drugs. She is married with no children; she volunteers at her church, sings in the choir, and performs charity work with older people. Her family history is noncontributory.

Allergies: Penicillin (hives); no known food allergies.

Current Medications:

Levothyroxine 75 mcg, PO QD, Omeprazole, extended release 40 mg PO QD.

Morphine sulfate, extended release 60 mg PO QD, Lithium 300 mg, PO QD, Clonazepam 1 mg, PO qhs PRN insomnia/anxiety.

Desonide 0.05% topical ointment, apply sparingly to affected area(s) BID.

Albuterol inhaler, inhale two puffs q4h PRN, wheezing, dyspnea.

Physical Exam:

Vitals: T 37°C (98.6°F), P 76, R 12, BP 115/74, HT 152 cm (60 in.), WT 62 kg (138 lbs), BMI 27.

General: Well-developed, well-nourished female in no apparent distress.

Integumentary: Mild psoriasis in ears, scalp; skin is warm and dry, no edema or rash; no hair or eyebrow thinning; no nail pits or splitting.

Neck: Well-healed scar from parathyroid surgery, normal thyroid/neck exam.

Lungs: Clear to auscultation bilaterally. What other areas are you assessing and for what?

Cardiovascular: RRR, no murmurs, rubs, or gallops; no peripheral edema.

Abdomen: Soft, non-tender, non-distended, active bowel sounds in all quadrants, no hepatosplenomegaly or masses. What other areas are you assessing and for what?

Musculoskeletal: Lumbosacral region without tenderness or muscle spasm, limited active range of motion in lumbar spine. What other areas are you assessing and for what?

Neurologic: Lower extremity sensation intact, DTR 2+ patella, Achilles; negative SLR bilaterally. What other areas are you assessing and for what?

Psychiatric: Anxious, no pressured speech, good eye contact, good insight, no suicidal ideation.

Discussion and Clinical Review – Case Study

1. What other questions are pertinent to ask in the HPI?

2. What other descriptions, Pertinent areas would you focus on in the clinical exam: EX: If this were a respiratory case, what other respiratory system details would you list: “The chest wall is symmetric, without deformity, and is atraumatic in appearance. No tenderness is appreciated upon palpation of the chest wall. Bronchophony, Egophony etc.

3. Differential Diagnosis: Please list at least (and reference the background and pathophysiology with at least 2 sources for each) three differential diagnoses with the first diagnosis being your primary (most likely) diagnosis to demonstrate your understanding.

4. List at least 3 pertinent positives and at least 3 pertinent negatives for each differential

5. What if any diagnostic tests/imaging studies should be ordered and Why? Consider testing in the Primary and Acute care setting as well.

6. Following these diagnostic tests as per above, what is the next step, explain based on your differentials what you plan to do next and why.

7. Review a recent and credible research article about the key factors (causes, risks, diagnostic testing, and treatment selection) of this primary diagnosis. Provide references for your response in APA format. Your references should be within the past 3 years.

8. Patient education – Please document what is pertinent for education and why. Explain your education plan. As per the previous case study, you should be giving thorough detail to your education plan.

9. If not managed appropriately, describe in detail what are the medical/legal concern(s) that may result from mismanagement or deferral of interventions?

10. List any collaborative opportunities. Provide a list of any specialties or other disciplines and indicate what contribution these professionals might make to managing the patient.


APA FORMAT, AND REFERENCES, peer review scholarly resource cited in APA format from 2018-2023 only. (Within the last 5 years)

Please do not solely use a website as your scholarly reference, fine to use as supplement, but a journal article should be referenced or a text.

Please use reliable medical references such as your Goroll text, your Current Medical Diagnosis and Treatment book, or UpToDate.  Do NOT use WebMD, Wikipedia etc. as these are not advance practice references.  

APA format (if using outside sources).

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