Solve the Medical Riddle: The Patient Is No Longer “Regular”, Fourth Week

By Marie Savard MD

Editor’s note: Welcome to our ThirdAge feature that 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.

The first week of this riddle, the patient reported her symptoms and the doctor proceeded with the examination. This was step #1, S, of the classic the classic S-O-A-P notes as follows:
S=Symptoms or Chief Complaint
O=Objective Findings
A=Assessment or Analysis
P=Treatment Plan or Recommendations

The second week, the doctor moved on to O and A=Assessment or Analysis to continue to look for clues to the medical riddle. Last week, we let you know what some people had suggested as possible diagnoses. This week, the doctor will move on to P to reveal the actual diagnosis as well as outline treatment options and lifestyle recommendations. Then we’ll begin a new riddle for the following month!

The Doctor Reveals the Diagnosis

Congratulations to Mary S. who came the closest to the actual diagnosis for Sally’s chronic constipation when she said she thinks Sally just “holds it too long”! Thumbs up also to Carol M. who questioned whether Sally is drinking enough water. In view of Sally’s history of reduced physical activity/exercise, reluctance to use the toilet near the teachers’ room at the school, and her habit of postponing bowel movements, I diagnosed Sally with a problem that is popularly called “safe toilet syndrome”. This is a surprisingly common issue, especially, for women. The diagnosis does not have an ICD 9-CM code (soon to be ICD-10)
, by which I mean the International Classification of Diseases, Ninth Revision, Clinical Modification. That is the official system used in the United States to classify and assign codes to health conditions.
Even so, the actual label or precise diagnostic name is less important than the cause. Sally was quit literally afraid to use a toilet away from the safety of her own bathroom, especially if she felt others could hear her efforts to have a bowel movement.

Beyond that, she had experienced multiple lifestyle and functional changes that led to unhealthy modifications in her daily routine. Fortunately, though, she was not taking any offending over-the-counter supplements such as calcium carbonate, which is the form of calcium most likely to cause constipation, or multivitamins with iron, which is another cause of constipation. She was also not on any prescription medications that might cause constipation, such as calcium channel blockers to treat high blood pressure.

One of the main contributing factors to Sally’s constipation was her lack of exercise since she used to walk to and from school and now she drives, and she doesn’t play tennis or chase after her grandchild any longer.

Another factor was her diet, which had become unhealthy after she took the job at the school farther away from her home and felt rushed in the morning. Grabbing a power bar for breakfast instead of having a healthy meal definitely played into the condition.

The doctor told Sally she needed to eat about 15 to 20 grams of fiber a day to ensure adequate stool bulk. Good sources of insoluble fiber — which is best for bulk — are bran, vegetables, and fruits. Oat and grains are good sources of soluble fiber that also help with bulk and can lower cholesterol. Beyond that, over-the-counter fiber supplements with psyllium husks are great for people who need added bulk during the transition as the diet changes for the better. Metamucil is one popular brand. Osmotic laxatives such as sorbitol or stool softensers can be added if the extra time for the bathroom, increased fiber, fluids and exercise is not enough. As Carol M. suspected, Sally needed to increase her fluid consumption in order for the fiber to work best. Fluids are also good for softening stools.

Finally, Sally needed to set her alarm for an earlier time so that she can eat breakfast and restore her morning bowel movement routine at about the same time every day before she leaves for school. Early morning coffee also stimulates the colon, and that can help. A daily bowel movement is not essential, depending on the person, but establishing a great diet and healthy routine is paramount.

The doctor told Sally not to start taking laxatives, which can in fact cause the bowel to stretch excessively and lose muscle tone and cause constipation if they’re overused. Adding stool softeners, glycerin suppositories and/or An enema to get rid of the impacted stool might be needed) but this would rarely happen in with a person Sally’s age although it can be more common in the elderly for whom stool really is impacted). The doctor felt that if Sally followed all the recommendation, the problem would resolve itself without an enema.

Sally was strongly motivated to do just what the doctor ordered. A month later, she came back for a check up and reported that she never needed an enema and that the problem had been resolved.

“What a difference a few weeks can make!” she said. “I feel like my old self again. I’ve started getting up an hour earlier so I can have a good breakfast such as bran cereal with Greek yogurt and blueberries. I then use the bathroom before I get in the car to go to work. Also, even though we have playground monitors, I now go out with the kids during recess. I not only get some exercise and fresh air, but my students and I have really bonded over this activity.

“I still hate using the bathroom next to the teachers’ room. I guess I’m old-fashioned that way. But that’s not an issue now that I’ve adjusted my morning routine. Best of all, I’m playing tennis again and spending a lot of time with my granddaughter. My daughter is thrilled and so am I. Solving the constipation issue has made me feel years younger and really glad to be alive!”

Come back to next Thursday when we’ll introduce a new medical riddle!

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

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