Solve the Medical Riddle: “What’s Wrong with Me?”
Editor’s note: Welcome to our new ThirdAge feature, which gives you a chance to play medical sleuth as we share the details of what happened when a patient presented with a problem that stumped the physician at first.
We’ll start this week by letting you know what the patient told the doctor and how the doctor proceeded with the examination. Next week, the doctor will continue to look for clues to the medical riddle. The third week, we’ll let you know what some people have suggested as possible diagnoses. The fourth week, the doctor will reveal the actual diagnosis and outline treatment options and lifestyle recommendations. Then we’ll move on to a new riddle for the following month!
The Patient’s Reports Her Symptoms
Sally G., a 53-year-old first grade teacher, presented with severe constipation.
Her doctor used the classic S-O-A-P notes as follows:
S=Symptoms or Chief Complaint
A=Assessment or Analysis
P=Treatment Plan or Recommendations
This week, we’ll cover S, Symptoms or Chief Complaint. Here’s what Sally told the doctor:
“I used to be regular, like clockwork. I’d eat my breakfast and go to the bathroom right after that, no problem. Then a year ago, I took a new and better paying job at an elementary school about an hour’s drive from my house. The old school was a ten-minute walk away. Now I most often skip breakfast and eat a power bar in the car. That’s the only change I can think of in my daily routine. I bring a healthy lunch the way I always did, usually a turkey sandwich on brown bread and raw veggies or an apple. For dinner I serve fish or chicken for our entrée and make a salad. We almost never have dessert.
Wait! I just remembered a couple of other changes that have come about because of my problem. My husband and I love to play tennis and we used to get out on the courts every Saturday morning. But now that I’m not having bowel movements every day, I feel so bloated and uncomfortable that I’ve started staying home on Saturdays and just reading or watching TV.
Also, I used to babysit for my one-year-old granddaughter fairly often but I just don’t have the energy to keep up with her these days.
Sometimes once I start teaching in the morning, I do have the urge to have a movement. However, there’s no way I can leave a roomful of six-year-olds alone. I hold it until lunchtime but the bathroom is right off the Teacher’s Room where we eat and you can hear everything that goes on in there. I hate the idea of having male teachers listen to my, um, efforts on the toilet. I just keep holding it until I get home in the evening but by then the urge is usually gone.
I hope you can help me. I’ve tried Milk of Magnesia but it actually doesn’t do much for me. I just can’t go on like this!”
After hearing Sally’s complaint, the doctor considered the following causes as a start toward reaching a final diagnosis:
Acute constipation, which usually comes on suddenly and can be caused by:
o Bowel obstruction
o Certain medications and supplements.
Chronic constipation may be caused by:
o Colon tumor
o Hormonal or metabolic disorders such as diabetes
o Low thyroid
o Low or high calcium levels
o Kidney disease
o Brain and neurologic disorders such as Parkinson’s, stroke, Multiple Sclerosis, or spine problems
o Systemic or autoimmune disorders such as Lupus and scleroderma
o Functional disorders (meaning not organic or physiologic), including:
*Slow stool transit, often from chronic laxative use
*Irritable bowel syndrome
*Pelvic muscle weaknesses or prolapse
*Dietary choices such as white foods with low fiber content (rice, pasta, bread, potatoes, bananas) and cooked vegetables because heat breaks down fiber
The doctor then ascertained Sally’s lifetime of:
• Stool frequency
• Stool consistency
• Use of laxatives
• Whether there has been blood in the stool that could signal fissures from straining, hemorrhoids, or possibly cancer
• Whether there has been pain with bowel movements that could signal irritable bowel syndrome, also known as spastic colon
• Time typically spent in having a BM on toilet. Some patients deny a problem in past but admit to 10 to 20 minutes of time on toilet!
Next the doctor did a Review of Systems (ROS) to look for possible causes of the constipation such as weight loss that could signal thyroid problems, cancer, excessive dieting, or an eating disorder. The doctor then took a complete dietary and medication history including over-the-counter and prescription drugs and supplements. She also asked about daily fluid consumption.
Finally, the doctor checked her notes to find out whether or not Sally had a colonoscopy at age 50 when the screening was recommended. Fortunately, Sally did have the screening and the results were negative so the doctor did not recommend a repeat screening, especially since Sally had no family history of colon problems such as polyps or cancer.
During the visit, the doctor ruled out the following medications as possible causes of Sally’s complaint since Sally was not taking any of them:
• Anticholinergics for Chronic Obstructive Pulmonary Disease (COPD)
• Calcium tablets
• Narcotics for pain
• Blood pressure medications such as calcium channel blockers
The doctor asked Sally to make an appointment for the following week so the evaluation could continue. Sally was instructed to fast, meaning not to have any food or beverages except water for eight hours prior to the appointment, because the doctor planned to draw a blood sample to send to a lab for analysis for “fasting glucose” among other results. The doctor also planned to send a urine sample to the lab for analysis.
To be continued . . .
Come back to ThirdAge.com next Thursday to learn how the doctor moved on to O, Objective Findings, and A=Assessment or Analysis in her quest for a correct diagnosis of Sally’s complaint.
Marie Savard, M.D., a former Medical Contributor for ABC News and a frequent keynote speaker around the world, is one of the most trusted voices on women’s health, wellness, and patient empowerment. She is the author of four books, including one that made the Wall Street Journal list of the best health books of 2009: “Ask Dr. Marie: What Women Need to Know about Hormones, Libido, and the Medical Problems No One Talks About.” Dr. Marie earned a B.S. in Nursing and an M.D. degree at the University of Pennsylvania. She has served as Director of the Center for Women’s Health at the Medical College of Pennsylvania, technical advisor to the United Nations’ Fourth World Conference on Women in Beijing, advisor to the American Board of Internal Medicine Subcommittee on Clinical Competency in Women’s Health, health columnist for Woman’s Day magazine, and senior medical consultant to Lifetime Television’s Strong Medicine. Pleas visit DrSavard.com
To read the archive with all of our “What’s Wrong with Me?” features, click here.