Bedside Diagnostic Challenge

A 16-year-old girl with lack of bowel movements.

Test your bedside diagnostic skills with this free clinical case question.

Patient Case:

A 16-year-old girl is brought to her physician because of lack of bowel movements.

The patient states that for the past 3 months, she has had a bowel movement only every other week. She describes them as normal in color and consistency.

She has had no abdominal pain or soreness. She notes some fatigue and infrequent menses which previously were regular.

She has been eating well but has lost a few pounds. She has been urinating a bit more frequently than normal but has no urinary tract symptoms. She complains of cold hands and feet.

She takes no medications and denies using alcohol or illegal drugs. Her mother adds that her daughter is “spending too much time in the bathroom.”

Physical examination reveals a pleasant, slightly thin young woman who does not appear ill.

Vital signs show:

Temperature of 96.80F,
Blood Pressure of 96/50 mmHg,
Pulse of 54 and regular, and
Respirations of 12 /minute.

BMI is 17 kg/m².

Her hands and feet are cold and slightly blue. The skin is otherwise normal. The dental enamel is slightly pitted. The thyroid gland is palpable but without nodules. The abdomen is scaphoid but otherwise normal. Rectal examination reveals an empty ampulla and a palpable, normal sized uterus.

Question:

Based on the diagnostic value of careful examination...

Which symptom, not asked about in the medical history, would have been most helpful; and what test or tests would be most helpful in supporting a diagnosis?

Answer Options:

Vomiting; electrolytes.

Voice change; gastric analysis.

Thirst; kidney function studies.

Night sweats; colonoscopy.

See the Answer:

The correct answer is:

Vomiting; electrolytes

Key Point:

Prolonged intervals between bowel movements suggests little food getting beyond the stomach.

Explanation:

This patient most likely has anorexia (bulimia/purging type) with repeated vomiting resulting in little food getting beyond the stomach, thus the infrequent bowel movements.

Bradycardia, hypotension, cold extremities and hypomenorrhea are all signs of hypometabolism, consistent with the diagnosis of anorexia.

The pitting of her teeth is an indication of loss of enamel through repeated exposure to gastric acid. Finally, the infrequency of bowel movements in a late adolescent, added to the rest of the findings, leads to the preliminary diagnosis of anorexia.

Of course, the patient could have denied vomiting but often some hesitation or unexpected body language is observed when asked about this symptom.

Hypotension and polyuria could suggest adrenal insufficiency but a slow pulse speaks against the diagnosis as does the pronounced infrequency of bowel movements.

The combination of bradycardia and low body temperature could suggest hypothyroidism but low blood pressure would not be expected and, like adrenal insufficiency, the striking absence of bowel movements exceeds the degree of constipation observed in patients with hypothyroidism.

Anorexia with repeated vomiting will result in a hypokalemic, hypochloremic alkalosis, the result of gastric fluid losses from vomiting. None of the other diseases in the differential diagnosis would result in electrolyte abnormalities or abnormal kidney function studies.Gastric analysis should be normal. Colonoscopy in this young woman would not be expected to be abnormal, regardless of which diagnosis was correct.

Other elements of the history that were not asked (thirst, voice change, or night sweats) could support diagnoses of adrenal insufficiency, hypothyroidism, and inflammatory processes respectively) but are not observed in patients with anorexia.

An important point in this case is that when the history and physical examination present a confusing mix of symptoms and signs, it is wise to go back over the patient’s history and ask oneself whether some aspect of the history that was not asked about might be helpful to explore.In this case, of course, it was the failure to ask about vomiting.

This case reinforces the importance of a good history and physical examination, leading to a much narrower set of diagnostic possibilities and thus more targeted laboratory studies and/or diagnostic procedures.

Figure:

Tooth damage (pitting) in bulimic patient.

Tooth damage (pitting) in bulimia, anorexia

References:

Kreipe RE, Starr, TB. Eating Disorders. Nelson Textbook of Pediatrics. 2020; 41: 228-236.e1

Tanofsky-Kraff M. Eating Disorders. Goldman-Cecil Medicine. 2016; 206: i416-1418.e1

About The Bedside Diagnostics Blog Series:

Except for Hospitalists, Emergency Medicine physicians, and Interventional Cardiologists, most physicians will spend the bulk of their professional time with patients in an office setting.

Here is where finely tuned clinical skills are most important in leading to accurate diagnoses, fewer complications resulting from unnecessary tests and procedures, and lower costs. These Bedside Diagnostic Challenges reinforces the value of these clinical skills and tests users on their knowledge of them.

Bedside Diagnostic Challenge questions are issued periodically every month as a free benefit of Med-Challenger.

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About the Author:

Paul Griner MD, MACP graduated from the University of Rochester School of Medicine and completed his residency at the Massachusetts General Hospital, Boston, MA. He has served the University of Rochester School of Medicine as Chief Resident in Medicine and as Professor, Department of Medicine. He has served as a Senior Lecturer at Harvard Medical School and consultant at the Massachusetts General Hospital where he introduced a mentoring program for the faculty of General Internal Medicine. Dr. Griner is board certified in internal medicine.

Bedside Diagnostic Challenge – 16-year-old girl with lack of bowel movements

Bedside Diagnostic Challenge

Patient Case:

Question:

Which symptom, not asked about in the medical history, would have been most helpful; and what test or tests would be most helpful in supporting a diagnosis?

See the Answer:

The correct answer is:

Vomiting; electrolytes

Key Point:

Explanation:

Figure:

References:

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Bedside Diagnostic Challenge

Patient Case:

Question:

Which symptom, not asked about in the medical history, would have been most helpful; and what test or tests would be most helpful in supporting a diagnosis?

See the Answer:

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