American College of Physicians: Internal Medicine — Doctors for Adults ®

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In the News
for the Week of 7-1-08

Highlights

  • Congress fails to prevent drastic Medicare cuts
  • Socioeconomic status affects cancer survival, study finds

Hypertension

  • Web program and pharmacist contact can reduce blood pressure
  • Urinary albumin in normal range may predict hypertension, study finds

Geriatrics

  • Half of elderly fall deaths come from traumatic brain injury, study finds
  • Simple exam may predict cognitive, stroke and death risks for elderly

Warnings and alerts

  • Tamsulosin associated with intraoperative floppy iris syndrome
  • Tainted tomato outbreak expands to 34 states

Tools and resources

  • PIER introduces interactive feature
  • National forum on cancer planned

MKSAP

  • MKSAP quiz: Abdominal pain

From ACP Internist

  • Mindful Medicine case studies wanted
  • What they're saying on the blog

From ACP Hospitalist

From the College

  • Earn a Medicare bonus for reporting quality information
  • ACP to collaborate with Center for Health Care Engineering

Editorial note: ACP InternistWeekly will not be published on Tuesday, July 8 due to the July 4th holiday.


Highlights

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Congress fails to prevent drastic Medicare cuts

The Senate last week failed, by one vote, to pass legislation that would have prevented a 10.6% cut to physician payments under Medicare. The cut will now go into effect on July 1.

Earlier in the week the House of Representatives had passed the Medicare Improvements for Patients and Providers Act of 2008 (H.R. 6331) by an overwhelming majority of 355 to 59. The legislation was brought up by the Senate on Thursday; however it garnered only 59 of the 60 votes necessary for it to proceed to an official vote. With this impasse occurring in the Senate, and the House having already adjourned for a week for the July 4th holiday, all possibilities of having legislation passed and signed into law in time to stop the cut have been exhausted.

The legislation, as passed by the House, would have continued current payment rates through the end of the year and provided a 1.1% update on Jan. 1, 2009. In addition, it would have approved other ACP-supported improvements in Medicare payment policies, including: increased payments for office visits, increased funding of the Medicare medical home demonstration project and expanded coverage of preventive services. The legislation also would have phased out higher co-payments for mental health benefits.

In a letter to ACP members, President Jeffrey P. Harris, FACP said, “Despite your and the College’s valiant efforts, the process has failed you, and most importantly, it has failed your patients. ACP is already mounting an aggressive campaign to reverse the cuts.”

ACP is asking members to contact their congressional representatives to let them know how the cuts are affecting your practices and patients. ACP’s Legislative Action Center has more information about how legislators voted, and how ACP members can contact their representatives.

“As you communicate with your members of Congress, it is important to recognize that most of them voted with us,” Dr. Harris continued. “Although those lawmakers deserve credit for their efforts, they need to be reminded that the process still failed, and that they need to do everything necessary to make reversal of the cuts the first order of business.”

More information about how the cuts may affect your practice and your claims is online.

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Socioeconomic status affects cancer survival, study finds

Cancer patients with low socioeconomic status are less likely to survive the disease, in large part because they are diagnosed later and receive less aggressive therapy, a new study found.

Researchers collected data from seven state cancer registries about cancer stage, treatment received and five-year mortality rate for three common cancers. The study included records from 4,844 women with breast cancer, 4,332 men with prostate cancer and 4,422 men and women with colorectal cancer. Patients’ socioeconomic status was calculated using census data on the average income and education level of their neighborhoods.

For all three of the cancers, low socioeconomic status was associated with more advanced disease stage and less aggressive treatment. After adjustment for age, breast cancer and prostate cancer patients with low socioeconomic status had a significantly higher risk of all-cause mortality in five years (hazard ratios, 1.59 and 1.33, respectively). Adjustment for race/ethnicity, comorbid conditions, cancer stage and treatment reduced the association. The association between socioeconomic status and mortality was weaker for colorectal cancer.

Researchers noted that patients who were age 65 and older faced far less disparity, which they concluded was likely due to Medicare access to cancer screening and treatment. They concluded that in future studies of cancer disparities, socioeconomic status should be an important consideration, in addition to race and ethnicity. The study was published early online and will appear in the Aug. 1 issue of the journal Cancer.

The study and a press release are online.

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Hypertension

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Web program and pharmacist contact can help reduce blood pressure

A pharmacist-assisted, web-based program was shown to improve hypertension control in a recent study.

The trial randomized 778 patients with uncontrolled essential hypertension to receive usual care or home blood pressure (BP) monitoring and training on a patient Web site through which they could e-mail their physician, or home monitoring and the Web site plus online pharmacist care management. The study was conducted between June 2005 and December 2007 and the primary outcome was percentage of patients with controlled BP (under 140/90 mmHg). The study was published in the June 25 Journal of the American Medical Association.

Significantly more patients in the pharmacist care group achieved control (56%) than in either the home monitoring and Web (36%) or usual care groups (31%). Researchers concluded that the study showed how both internet care management and a chronic care model can improve hypertension control. They noted that the study was limited by its exclusion of patients without internet access, who tended to be older, minorities and less educated than the studied patients.

An accompanying editorial concluded that such Web management could be cost-saving (by reducing office visits) as well as effective, but that under current reimbursement structures, it is only feasible for group health systems like the one studied. Other physicians would have to spend money to integrate the Web systems into practice, pay for the pharmacist’s time, and then receive less reimbursement for fewer office visits, the editorialist said.

The study and editorial are online.

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Urinary albumin in normal range may predict hypertension, study finds

The risk of developing hypertension appears to be higher in healthy people who have normal to high levels of albumin excretion, according to a recent study.

The study in July online edition of the Journal of the American Society of Nephrology looked at 2,179 post- and pre-menopausal women enrolled in the Nurses Health Study without baseline hypertension or diabetes and normal levels of urine albumin. Women who had an albumin/creatinine ratio in the highest quartile (4.34 to 24.17 mg/g for older women and 3.68 to 23.84 mg/g for younger women) were more likely to develop hypertension than those who had an albumin/creatinine ratio in the lowest quartile. The findings held true regardless of body mass index, blood pressure, smoking or family history of hypertension.

The study suggests that the definition of “normal” urinary albumin excretion should be reconsidered said a June 24 news release from the American Society of Nephrology. The authors suggested that higher urine albumin levels may warrant monitoring for hypertension and possible treatment.

The news release[PDF] and article[PDF] are online.

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Geriatrics

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Half of elderly fall deaths come from traumatic brain injury, study finds

Traumatic brain injuries accounted for half of fall deaths and 8% of nonfatal fall-related hospitalizations among elderly adults in 2005, a new CDC study found.

Researchers analyzed 2005 data from the National Center for Health Statistics, the National Vital Statistics System and the Agency for Healthcare Research and Quality’s Nationwide Inpatient Sample. Findings include:

  • Men are more likely to die from fall-related traumatic brain injuries (TBIs). They had 26.9 deaths per 100,000 TBIs, compared with 17.8 deaths per 100,000 TBIs for women;
  • Fall-related TBI hospitalizations were similar for men (146 per 100,000) and women (158 per 100,000);
  • Death and hospitalization rates for fall-related TBIs increased with age; and
  • Most men and women hospitalized with fall-related TBI spent two to six days in the hospital (54.9% of men, 61.5% of women.) Median charges for the hospitalizations were $19,191 for men and $16,006 for women.

One in three older Americans falls each year, and falls are the leading cause of injury deaths and nonfatal injuries for those age 65 and older. In 2005, there were 7,946 fall-related TBI deaths and an estimated 56,423 hospitalizations for nonfatal fall-related TBI. The findings were in the June issue of the Journal of Safety Research.

Study limitations include the fact that hospitalizations may have been underestimated, since 17.1% of the TBI cases were missing the cause of injury and it’s likely many of these were fall-related. The analysis also didn’t include people who were treated and discharged from emergency departments, who sought care in outpatient clinics and physician offices, and who didn’t seek medical care. Overall, the results highlight the need to advertise and prioritize fall prevention measures, the study authors said.

The Journal of Safety Research article is online[PDF] via the CDC.

The CDC news release is online.

Fall prevention and brain injury resources for patients and health professionals are available online through the CDC.

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Simple exam may predict cognitive, stroke and death risks for elderly

A simple neurological exam may help predict cognitive and functional decline, as well as mortality and cerebrovascular risks, in older adults, a new study found.

Researchers evaluated 506 Italians with a mean age of 72 years who had no history of stroke, parkinsonism, dementia or cognitive impairment, for 15 subtle-- but clinically detectable-- neurological abnormalities (SNAs). Evaluations included elements like diminished deep tendon reflexes and handgrip. Each patient received a composite score by adding up the SNAs detected during the exam. Cognitive status and disability were evaluated again four years later, and deaths and cerebrovascular events were recorded over the next eight years. The study was published in the June 23 Archives of Internal Medicine.

More than half of the subjects had a composite score of at least one, and 14% had a score of more than 3. Scores increased with age and with declining cognitive and physical performance, depressive symptoms, and disability, but not with falls and urinary incontinence. Compared to a score of less than 3, a composite score of 3 or higher was associated with a 77% higher adjusted risk of death and a 94% higher risk of cerebrovascular event over eight years. Death rates of 22.6, 23.3, 23.9, 58.6, and 91.9 per 1,000 person-years matched scores of 0, 1, 2, 3, and 4 or higher, respectively. Scores also predicted declining cognitive status and disability.

The composite score is probably less sensitive than neuroimaging and is thus of limited use in etiologic studies, but because it is expensive and easy, it may be useful in epidemiologic studies and in clinical practice, the researchers said. Editorialists agreed the study results merit more research into the possibility of routinely using composite SNA scores to identify elderly adults at risk of disability and enroll them in disability prevention trials.

The Archives of Internal Medicine study is online.

The Archives of Internal Medicine editorial is online.

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Warnings and alerts

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Tamsulosin associated with intraoperative floppy iris syndrome

Patients who have taken tamsulosin (Flomax), a systemic alpha-1 adrenergic antagonist commonly prescribed for benign prostatic hyperplasia, are at higher risk for intraoperative floppy iris syndrome (IFIS) during cataract surgery, said the American Academy of Ophthalmology and the American Society of Cataract and Refractive Surgery in a joint statement.

IFIS has also been reported with non-subtype specific alpha-1 adrenergic antagonists, such as terazosin (Hytrin), doxazosin (Cardura), and alfuzosin (Uroxatral), but is more likely to occur with tamsulosin, according to several studies referenced by the statement. Clinical manifestations of IFIS complicating cataract surgery include poor preoperative pupil dilation, iris billowing and prolapse, and progressive intraoperative miosis.

In a 2008 online survey of ASCRS members, cataract surgeons reported an increased rate of significant iris damage (52% of respondents) and an increased rate of posterior capsule rupture (23% of respondents) in eyes with IFIS during the past two years. Prescribing physicians may wish to consider involving the patient's cataract surgeon prior to initiating non-emergent, chronic tamsulosin or alpha blocker treatment in patients with cataracts, said the statement. Options might include an eye exam or having either the patient or the prescribing physician communicate with the cataract surgeon. Patients should also be encouraged to report any prior or current history of alpha-1 antagonist use to their ophthalmic surgeon prior to undergoing any eye surgery.

The joint ASCRS/AAO educational update statement for physicians is online.

Results of the survey are published in the July 2008 Journal of Cataract and Refractive Surgery[PDF].

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Tainted tomato outbreak expands to 34 states

The salmonella outbreak from raw red tomatoes has expanded to include more than 756 cases in 34 states and the District of Columbia, the CDC said last week.

At least 95 patients have been hospitalized from the outbreak involving Salmonella Saintpaul. The data suggest illnesses are linked to consumption of raw red plum, red Roma, or round red tomatoes, the CDC said. Most infected persons develop diarrhea, fever, and abdominal cramps 12-72 hours after infection, which is usually diagnosed by culture of a stool sample.

The CDC update on its investigation is online.

The FDA update on tomatoes safe to eat is online.

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Tools and resources

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PIER introduces interactive feature

PIER has introduced interactive user comment pages for 10 of its disease modules. Users can trade clinical insights and questions with colleagues, discuss important new data in the medical literature, and suggest additions and changes to PIER modules. The new feature is now available in the following areas:

Acute coronary syndromes
Atrial fibrillation
Community acquired pneumonia
Deep venous thrombosis
Depression
Diabetes mellitus, type 2
Essential hypertension
Heart failure
Lipid disorders (dyslipidemia)
Stroke and transient ischemic attack

PIER invites general suggestions and opinions about this feature. Send your comments to gklaiman@acponline.org so that we can continue to adapt and improve it to best meet the needs of ACP Members.

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National forum on cancer planned

Coming Together 2008: A National Forum on Cancer Care in the United States, an event aimed at raising awareness of legislative and regulatory issues affecting cancer patients, will be held July 14-15 in Baltimore.

Anyone involved in the delivery of cancer care and supportive services, cancer research, cancer advocacy, and legislative and regulatory leaders is welcome to attend. Sponsored by the American College of Surgeons' Commission on Cancer (COC), the meeting has several principal objectives:

  • To examine the legislative and regulatory issues having an impact on cancer care;
  • To discuss government involvement in research, funding, access, and supportive care issues for the cancer patient;
  • To educate participants on the role and impact of advocacy at national and local levels;
  • To instruct participants on ways to “make their voices heard” on the Hill; and
  • To identify legislative priorities for the COC and its member organizations.

The fee for the conference is $525 per person. Register by July 1 online.

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MKSAP

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MKSAP quiz: Abdominal pain

ACP InternistWeekly has brought back its MKSAP quiz. This popular feature was so heavily requested by our readers that we’re now offering it in our weekly news updates.

Case Study:
A 56-year-old woman is evaluated for abdominal bloating, abdominal pain, and diarrhea. She had laparoscopic Roux-en-Y gastric bypass surgery 2 years ago for morbid obesity; since her surgery, she has had two or three soft bowel movements per day, but over the past 4 months she has had frequent episodes of diarrhea, with four to six loose bowel movements per day. She has also had bloating, belching, and flatulence resulting in abdominal cramping that is relieved by a bowel movement. She does not have hematochezia, melena, or mucoid stools. She lost 45.5 kg (100 lbs) in the first year after surgery, at which time her weight stabilized, but she has lost an additional 4.5 kg (10 lbs) since her current symptoms began. In addition to her surgery for obesity, her medical history includes type 2 diabetes mellitus and obstructive sleep apnea (both of which resolved postoperatively with weight loss) and mild bilateral osteoarthritis of the knee; her medications include monthly vitamin B12 by subcutaneous injection, ferrous sulfate, a daily multivitamin, and acetaminophen as needed. She has not had any recent travel, antibiotic therapy, changes in medication, or exposure to sick persons, young children, or pets. She had a normal colonoscopy 1 year ago.

Vital signs are normal; BMI is 28. Physical examination reveals abdominal surgical scars; the abdomen is not distended or tender, and bowel sounds are normal.

Complete blood count Normal
Glucose 105 mg/dL (5.8 mmol/L)
Thyroid-stimulating hormone 3.5 μU/mL (3.5 mU/L)
Folate 33 ng/mL (74.8 nmol/L)
Ferritin 80 ng/mL (80mg/L)
Vitamin B12 500 pg/mL (369 pmol/L)
IgA 150 mg/dL (1.5 g/L)
Anti-tissue transglutaminase antibodies (IgA) 5 U/mL (normal)

Which of the following is the most likely diagnosis?

A. Unmasked celiac sprue
B. Giardiasis
C. Pancreatic insufficiency
D. Small intestinal bacterial overgrowth
E. Irritable bowel syndrome

Click here or scroll to the bottom of the page for the correct answer.

For reference, a full list of normal laboratory values is online[PDF].

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From ACP Internist

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Mindful Medicine case studies wanted

What was your most difficult diagnosis?

ACP Internist columnists Jerome Groopman, FACP, and Pamela Hartzband, FACP, would like to hear about your stories of difficult or missed diagnoses for possible use in their next 'Mindful Medicine' column.

Dr. Groopman, a hematologist/oncologist and author of the bestselling "How Doctors Think," and Dr. Hartzband, an endocrinologist, are on the Harvard Medical School faculty and serve as staff physicians at Boston's Beth Israel Deaconess Medical Center. Every other issue, they present a case study from an ACP Internist reader describing a difficult or missed diagnosis, and provide commentary on how a mistake was, or might have been, avoided.

Please email your suggestions to Drs. Groopman and Hartzband. The authors will contact you to discuss the case if your submission is selected for the column.

Previous Mindful Medicine columns are online.

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What they're saying on the blog

Join the ACP Internist's community on its blog, featuring daily updates on news that just can't wait. Find popular features such as Medical News of the Obvious. Post your comments today.

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From ACP Hospitalist

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Recommend your colleagues as Hospitalists of the Year

ACP Hospitalist is seeking candidates for its first annual Hospitalists of the Year issue. To recommend a colleague who made notable contributions to the field in 2008, whether through cost savings, improved work flow, patient safety, leadership, mentorship or quality improvement, readers can fill out the online form. All recommendations must be received by July 14. Hospitalists of the Year will be profiled in our November 2008 issue.

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From the College

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Earn a Medicare bonus for reporting quality information

ACP is co-hosting a forum via conference call with the CMS to discuss internist participation in the Medicare 2008 the Physician Quality Reporting Initiative (PQRI), a program that pays physicians a bonus for reporting quality data to CMS on their claims forms.

PQRI was first introduced in July 2007 and was renewed for 2008, with the reporting period starting in January. It awards a bonus payment of 1.5% of allowable charges for Medicare patients to physicians who successfully submit quality data.

The toll-free call will take place on Tuesday, July 15, 2008 from 3:30 to 5:00 p.m. EST. Internists and/or a designated staff member, such as an office manager, are invited to dial in to hear about PQRI participation options, including new mechanisms available beginning July 1. You are still able to participate and earn a bonus even if you have yet to report quality data for 2008. The focus of the call will be on the steps that internists need to take to collect and report the necessary quality data for participation in the program. Callers will have an opportunity to ask questions and receive answers from both ACP and CMS experts.

Members who wish to participate should call-in at (800) 837-1935 and enter the conference ID number: 53531371.

More information about the call and the PQRI program is available online.

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ACP to collaborate with Center for Health Care Engineering

ACP has entered into an agreement with Purdue University’s Regenstrief Center for Health Care Engineering to collaborate on research into health care reform. Specifically the College and the Regenstrief Center will be collaborating on projects that apply the principles of engineering, management and science to the reform of health care-delivery systems.

The Regenstrief Center was created in 2005 to apply the concepts of engineering and production to health care delivery. The Center receives core funding support from the Regenstrief Foundation, established by Sam Regenstrief, an authority on industrial production techniques who believed that the same techniques could provide better care at lower costs. The Center, located within Purdue University’s Discovery Park, takes an interdisciplinary approach health system research and partners with representatives of different components of the health care system.

The Center and ACP will be looking for opportunities for reform in the areas of: practice model development; patient scheduling; telehealth in chronic disease management; e-learning to support patients’ self care; and, factors in the primary care system affecting delivery of care consistent with clinical guidelines.

Further information about the Regenstrief Center can be found on the Purdue Web site.

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MKSAP Answer

D. Small intestinal bacterial overgrowth.

This patient likely has small intestinal bacterial overgrowth, which may occur after Roux-en-Y bypass surgery secondary to the surgical creation of blind loops of bowel that have relative stasis as shown in the following figure:

A small 50 mL pouch is made in the upper stomach, which is closed from the lower stomach with two staple lines. A Roux-en-Y loop is made with the jejunal end anastomosed to the small pouch. The gastric contents and the duodenal contents meet up when the two segments anastomose.


A small 50 mL pouch is made in the upper stomach, which is closed from the lower stomach with two staple lines. A Roux-en-Y loop is made with the jejunal end anastomosed to the small pouch. The gastric contents and the duodenal contents meet up when the two segments anastomose.



Patients with bacterial overgrowth typically have abdominal discomfort, bloating, distension, diarrhea, and excessive flatulence. Fat, carbohydrate, and protein malabsorption may all occur. Vitamin B12 deficiency may occur (in patients not receiving parenteral supplementation) due to competitive uptake of the vitamin by the bacteria, and folate levels may be elevated, as in this patient, secondary to increased production of folate by the bacteria. Quantitative small bowel cultures or breath testing can help to substantiate the diagnosis, and rotating antibiotics may be used for treatment. Other complications of bariatric surgery may occur perioperatively or late after surgery: perioperative complications include anastomotic leak, wound infection, hemorrhage, and venous thrombosis/embolism; late complications include dumping syndrome, strictures, vitamin and mineral deficiencies, and bowel obstruction or ulceration.

Although celiac disease may be unmasked after bariatric surgery, the normal tissue transglutaminase antibodies with a normal serum immunoglobulin IgA level in this patient make celiac disease less likely. Although infection with Giardia or other parasitic organisms could cause the patient’s symptoms, she has no risk factors for such an infection, and it would not explain her markedly elevated folate level. Although pancreatic insufficiency may be unmasked after bariatric surgery as well, bacterial overgrowth is much more common in this setting, and again would explain the elevated folate level. Although this patient does have some clinical features which would fulfill criteria for irritable bowel syndrome, the sudden nature of her symptoms and new weight loss would argue against that diagnosis.

Key Points

  • Perioperative complications of bariatric surgery include anastomotic leak, wound infection, hemorrhage, and venous thrombosis/embolism; late complications include bacterial overgrowth, dumping syndrome, strictures, vitamin and mineral deficiencies, and bowel obstruction or ulceration.
  • Small bowel bacterial overgrowth is common after Roux-en-Y bariatric surgery, and should be considered in the patient with diarrhea, bloating and excessive flatus.
  • Laboratory clues to the diagnosis of bacterial overgrowth include low vitamin B12 level (in patients not receiving parenteral supplementation) and elevated serum folate.

Return to the rest of ACP InternistWeekly

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ACP InternistWeekly is a weekly newsletter produced by the staff of ACP Internist. It is automatically sent to all College members who have an e-mail address on file with ACP.

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Copyright 2008 by the American College of Physicians.

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Test yourself

A 42-year-old woman is evaluated for an 8-month history of crampy abdominal pain and three loose bowel movements per day. The pain is relieved by a bowel movement. There are no nocturnal bowel movements, and there is no blood or dark tarry material in the stool. She has not had fever, night sweats, or weight loss. She has a history of Hashimoto disease and is treated with levothyroxine. Following a physical exam, rectal exam, and lab tests, what is the most appropriate next step in management?

Find the answer

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