Diagnostic Evaluation

The IBS Miracle

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In speaking with Mr. Stern, there appear to be several important diagnoses. Inflammatory bowel disease (IBD), irritable bowel syndrome, traveler's diarrhea, pseudomembranous colitis, celiac disease, and giardiasis are certainly in the differential diagnosis. The history of iritis and low back pain makes the diagnosis of IBD a strong possibility. IBD, consisting of Crohn's disease and ulcerative colitis, is very common, with an annual incidence in the United States of approximately 3 to 10 new cases per 100,000 people. Extraintestinal inflammatory manifestations are common. Ocular manifestations occur in 5% of patients with IBD, and ankylosing spondylitis, in 5% to 10%. The most common extraintestinal manifestation is a peripheral, large-joint, asymmetric, nondeforming arthritis; this occurs in 20% of patients with IBD. Mr. Stern does not have a history of this type of arthritis. Genetic disorders seem unlikely, inasmuch as the appearance of this patient's problem started at age 27 or 28. Viral or bacterial gastroenteritis also seems unlikely, because of the apparent chronicity of the problem despite the travel history 15 months ago to Central America. Salmonella, Shigella, and Campylobacter enterocolitis are generally associated also with fever and are short-lived infections, lasting from 3 to 6 days, although Campylobacter infection may cause a more protracted diarrheal illness. Antibiotic-associated colitis (pseudomembranous colitis) is unlikely, inasmuch as most of the symptoms antedated the use of the recently prescribed antibiotics. Colorectal carcinoma is unlikely because of the history and this patient's age. Giardiasis is still a possibility, but it is low on the list of differential diagnoses: Most patients with giardiasis exhibit a malabsorptive diarrhea, and lactase deficiency occurs frequently, in 20% to 24% of patients; Mr. Stern denies milk intolerance. The regular use of condoms by a man who has sex only with women makes the diarrheal illness less likely to be related to acquired immunodeficiency syndrome (AIDS). Diarrheal illnesses and malabsorptive syndromes can occur in as many at 50% of AIDS patients. Malabsorption syndromes are common. They are characterized by defective adsorption of fats, fat-soluble and other vitamins, carbohydrates, electrolytes, minerals, and water. Although chronic diarrhea and flatulence are common in malabsorption syndromes, the hallmark of malabsorption is excessive fecal fat content, or steatorrhea. Mr. Stern denies floating stools, a symptom of steatorrhea. Celiac disease is a chronic disease, but this patient's lack of sensitivity to gluten makes this diagnosis less likely. Vascular disorders are unlikely because of the age of the patient and the lack of other medical conditions.

On the basis of the history, the focused physical examination of Mr. Stern should include the following:

• General appearance for signs of wasting, jaundice Inspection of skin for rashes

Inspection of the mouth for oral ulcers Inspection of the abdomen

Light palpation of the abdomen in all four quadrants after auscultation Deep palpation of all four quadrants Percussion of the abdomen Evaluation of liver size

Rectal examination and evaluation for fecal occult blood

• Evaluation of sacroiliac joints for tenderness

After performing these physical examination maneuvers, you should be able to narrow down and/or confirm the most likely diagnosis. Always obtain as much information as possible. You can always narrow down your differential diagnosis.

The reader should review the DVD-ROM included with this book to see how this history and physical exam is performed.

It is a difficult task to obtain a good focused history and perform a good focused physical examination. It requires an excellent knowledge of physical diagnosis, pathophysiologic processes, and epidemiologic data in order to home in on the important aspects of the patient's medical problem.

Bibliography

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Bowen JL: Educational strategies to promote clinical diagnostic reasoning. N Engl J Med 355:2217, 2006. Bradley CP: Can we avoid bias? BMJ 330:784, 2005.

Drossman DA: Functional abdominal pain syndrome. Clin Gastroenterol Hepatol 2:353, 2004. Gandhi TK, Kachalia A, Thomas EJ, et al: Missed and delayed diagnoses in the ambulatory setting: A study of closed malpractice claims. Ann Intern Med 145:488, 2006. Heller RF, Sandars JE, Patterson L, et al: GPs' and physicians' interpretation of risks, benefits and diagnostic test results. Fam Pract 21:155, 2004. Jason H: Becoming a truly helpful teacher: Considerably more challenging, and potentially more fun, than merely doing business as usual. Adv Physiol Educ 31:312, 2007. King DB, Dickinson JA, Boulton MR, et al: Clinical skills textbooks fail evidence-based examination. Evid Based Med 10:131, 2005.

Lau AYS, Coiera EW: Do people experience cognitive biases while searching for information? J Am Med

Inform Assoc 14:599, 2007. Lembo A, Ameen VZ, Drossman DA: Irritable bowel syndrome: Toward an understanding of severity. Clin

Gastroenterol Hepatol 3:717, 2005. Manning-Dimmitt LL, Dimmitt SG, Wilson GR: Diagnosis of gastrointestinal bleeding in adults. Am Fam Phys 71:1339, 2005.

Peltier D, Regan-Smith M, Wofford J, et al: Teaching focused histories and physical exams in ambulatory care: A multi-institutional randomized trial. Teach Learn Med 19:244, 2007. Westbrook JI, Gosling AS, Coiera EW: The impact of an online evidence system on confidence in decision making in a controlled setting. Med Decis Making 25:178, 2005.

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Why Gluten Free

Why Gluten Free

What Is The Gluten Free Diet And What You Need To Know Before You Try It. You may have heard the term gluten free, and you may even have a general idea as to what it means to eat a gluten free diet. Most people believe this type of diet is a curse for those who simply cannot tolerate the protein known as gluten, as they will never be able to eat any food that contains wheat, rye, barley, malts, or triticale.

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