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NYU Medical Grand Rounds Clinical Vignette

NYU Medical Grand Rounds Clinical Vignette. Animesh Jain PGY3 9/27/2011. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

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NYU Medical Grand Rounds Clinical Vignette

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  1. NYU Medical Grand Rounds Clinical Vignette Animesh Jain PGY3 9/27/2011 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • The patient is a 45 year old female with a chief complaint of constipation that has been present for several years.

  3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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.

  4. 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.

  5. 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.

  6. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Past Medical History: • Irritable bowel syndrome (IBS) • Gastroesophageal reflux disease (GERD) • Asthma • Fibromyalgia • Major depressive disorder • Post-traumatic stress disorder (PTSD) • Trigeminal neuralgia

  7. 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

  8. 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

  9. 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

  10. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

  11. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 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

  12. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Colonoscopy (2002) • single 3mm hyperplastic polyp • left and right colon biopsies showed normal colonic mucosa. • Colonoscopy (2008) • Normal colonoscopy

  13. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working Diagnosis • The working diagnosis at this point was chronic constipation due to constipation predominant irritable bowel syndrome.

  14. 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.

  15. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Chronic constipation due to irritable bowel syndrome, with significant improvemet on lubiprostone.

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