A 28-year-old white woman presents to your office with a chief complaint of con­ stipation and abdominal pain. On further questioning, she reports she has had this problem since beginning college at the age of 18. Her symptoms have waxed and waned since this time, but never have worsened. She describes her abdomi­ nal pain as dull, crampy, and nonfocal but more prominent in the left lower quadrant, and improved with defecation. She denies radiation of pain, nausea, vomiting, fever, chills, weight loss, heartburn, or bloody or dark stool. She reports that over the last 3 months she is having cramps 7 to 10 times per month and hav­ ing a bowel movement every 1 to 2 days that is hard and feels incomplete. She has tried over-the-counter remedies, including stool softeners and antacids, but only experienced minimal improvement in her symptoms. She only takes birth con­ trol pills and denies any use of herbal supplements or laxatives. Her family history is negative, including for colorectal cancer and inflammatory bowel disease, and she reports that her parents and siblings are healthy. She is currently engaged and reports significant stress in preparing for the wedding. On physical examination, you note her to be somewhat anxious, but otherwise in no apparent distress. Her vital signs and general physical examination are normal. Her abdomen has normal bowel sounds, no tenderness on superficial and deep palpation, and no rebound, rigidity, or guarding. Liver and spleen size are within normal limits and no masses are palpable. A pelvic examination is normal. The rectal examination shows nor­ mal sphincter tone, no masses, and brown stool that is occult blood negative.

constipation | abdominal pain | dull pain | crampy pain | left lower quadrant pain | improved with defecation | months | hard stool | feels incomplete stools | stress | anxious

IBS

Lange Case files Family Medicine 4th Case 40 page 427