Case 2

 CHIEF COMPLAINT: "My bowels don't move right." 

HISTORY OF PRESENT ILLNFSS: The patient is a 68 year old woman who complains of a significant change in bowel movements during the past 6 weeks. She describes her bowel movements as being regular, once per day, up until 6 weeks ago. For the past 6 weeks she experienced 3-4 day periods of constipation alternating with non-bloody diarrhea.

 Although most bowel movements resulted in formed stools which were brown and of normal caliber, three days ago she passed a stool with streaks of bright red blood on the surface. The patient, however, was not alarmed because she occasionally suffers from bleeding hemorrhoids. 

During periods of constipation she feels bloated and senses a mild discomfort or pain in the abdomen. The pain is always generalized and seems to be relieved with defecation. She lost "a couple of pounds" recently but decreased her dietary intake to "keep my weight down." Even though she tires easily on some days, her health is good. She denies nausea, vomiting, melena, vaginal bleeding, dysuria, hematuria or frequency. She does complain of easy fatigability. 

The patient is 16 years post menopausal. Her gestational history is gravida 1, para 1. She was treated for dysmenorrhea as a younger woman. She is under the care of a physician for non­insulin dependent diabetes, osteoarthritis and glaucoma. Her doctor treated her six months prior to admission for "a touch of low blood." "He told me to take Geritol for a month to build up my blood."

 PHYSICAL EXAMINATION: The patient is a moderately obese woman who is alert and in no acute distress. Vital signs are as follows: Blood Pressure  152/82mmHg; Apical Heart Rate 92/minute and regular; Respiratory Rate 16/minute; Temperature 98.4°. 

Examination of the head and neck reveals bilateral cataracts and a pterygium of the left eye. Conjunctivae are pale. The auditory canals are packed with cerumen.

The breasts are large, pendulous and symmetrical. Masses are not palpable. There are senile hemangiomas of the skin of the chest. 

The lungs are clew by percussion and auscultation..   S₁ is loud; S₂ is split (physiologic). Abnormal heart sounds are absent.

The abdomen is soft, non-tender and slightly round. A 12 cm diagonal scar is present in the right hypochondrium. (Patient neglected to mention that she had a cholecystectomy in 1970).  Percussion reveals slight hepatomegaly; the liver edge is palpable. Bowel sounds are normoactive. Rectal exam reveals no masses. The stool is positive for occult blood. 

Pelvic examination reveals normal external genitalia. The vaginal mucosa is atrophic. A small cystocele is present when the patient strains. The uterus is small; there are no adnexal masses.

LABORATORY TESTS: Hemoglobin 9.9 g/dL; hematocrit 30%; normal chest x-ray, alkaline phosphatase 157 units; liver scan was ordered (results are pending), total bilirubin 1.8 mg/100 ml.