Illustrative Case

Now consider as an example the case of Mr. Roger Stern. Mr. Stern is a 29-year-old man who has come to the emergency room with a chief complaint of ''diarrhea and abdominal pain.'' What possible diagnoses are you thinking about? What pathologic conditions may be involved? Acute problems? Chronic problems? Some possibilities include genetic disorders, infectious diseases, diseases of immunity, neoplastic diseases, environmental problems, nutritional pathologic processes, vascular disorders, or traumatic conditions. Now try to narrow down the possible diagnoses by starting the interview:

Where is the pain in your abdomen?

Right here (pointing to his lower abdomen)

How long have you been having the abdominal pain?

I have been having diarrhea and abdominal pain for the past 3 months.

What was the reason you came in today?

I saw some blood mixed in the stools, and I got very scared.

I can understand your concern. I am glad you came in today. We will do everything possible to help you____Can you describe the pain?

It's crampy and comes in waves. I also have this bloating sensation in my abdomen all the time . . . it's as if gas is always there.

What makes the pain better?

What makes it worse?

Has there been a change in your life that has created more anxiety?

I guess my job has been rather stressful. I don't get along well with my bosses.

What type of work do you do?' I am a legal assistant.

On a scale of 1 to 10, with 10 being the worst, how would you describe the pain?

I guess the pain is about 5 to 7.

How does the pain affect your lifestyle?

I do go to work, but it's tough getting up all the time to go to the bathroom and making excuses.

When you have the pain in your abdomen, do you have pain in any other area of your body at the same time?

Have you noticed that the pain is worse when you're hungry ... or after meals?

No, it just comes and goes and is not related to eating.

Now let's talk about the diarrhea. Can you describe it for me?

The stool is very loose and sometimes watery. And today there was blood in it.

Was there blood in the toilet bowl?

No. It was kind of wrapped with the stool.

How many times did you see blood with your stool?

Three times!

Is there mucus in the stool? Yes, often. It's kind of stringy. Is the stool formed? Not really.

About how many bowel movements do you have a day? About 8 to 10 for the past week. Does the stool float? No.

Does it smell strange?'

No. [pause] Doc, do you think I have cancer?

Mr. Stern, it's really too early to say. I need to ask you some more questions, perform a physical examination, and do some other tests. When we have all the tests back, I will be in a better position to advise you. At this time, however, there are many things that it could be. Let me ask you a few more questions. Have you had a fever?

Have you noticed that milk or milk products make the diarrhea worse? No.

Have you noticed that wheat, oat, barley, or rye products make the diarrhea worse? No. I love bread and wheat products. They don't seem to make things worse. Do you drink alcohol?

Not really. Maybe one beer over the weekend at most. Have you had abdominal pain in the past?

I first noticed abdominal pain with watery diarrhea about 15 months ago. What happened then?

I was traveling with a friend to Central America. 4

Did you see a doctor?

Did you take any medications?

My friend gave me some Pepto-Bismol and Imodium for the pain and diarrhea. Did it help you?

The pain persisted on and off for about 3 weeks and then disappeared. Do you take other medications?

No. I have been in good health otherwise. I have no other problems. Have you had other episodes of abdominal pain?

The pain and diarrhea returned about 3 months ago, but the diarrhea was no longer watery. The stool was just very loose.

Have you seen any doctor about this problem?

Yes, I saw a local doc about 3 weeks ago who gave me some antibiotic for it. Do you remember the name of the antibiotic? It was Flagyl. Did it help you?

No. In fact, it seemed to make it worse, so I stopped taking it after 5 or 6 days.

Do you have nausea?

Not really.

Any vomiting?

How's your diet?

I think okay, but recently I'm not too hungry because of the abdominal pain and diarrhea.

Has there been any change in your weight?

I've lost maybe about 5 pounds in the past month.

Does anyone else in your family have a similar problem?

Have you ever had surgery? No.

Tell me about your parents' health.

My Mom is 54, and she's fine. My Dad died about 15 months ago from a sudden heart attack. He was 56. I miss him a lot.

I am sorry to hear about your father.

Thanks.

Do you have any siblings?

Yeah, I have an older brother who's fine. He's 31. Do you use any recreational drugs? Marijuana about once or twice a month. Anything else? No.

Do you have any allergies? No.

Are you sexually active? Yeah.

Are your partners male, female, or both?

Only women. I've got a great relationship going on now. I've been living with my girlfriend for the past 8 months. I sure hope it continues.

Do you use protection?

Mr. Stern, I just have a few more general questions before I begin the physical examination. Have you ever had a problem with your eyes?

Eyes . . . yeah. When I was 19 years old in college, I had iritis in my right eye. Tell me more about that.

I had real bad pain in my right eye, and it got real red. I saw the eye doc, who gave me steroids to take for about 4 weeks. I also remember that I had to wear sunglasses most of the time because the light really bothered me. I got better in about 3 weeks. I took all the meds because I didn't want that to come back again! Thank God it never came back!

Any history of back problems?

Yeah, I've had low back pain for several years since, I guess, I was 21. I think it's from too much bowling.

Did you ever see a doctor about it?

No. I just take some aspirin or Tylenol, which helps it.

Have you had any oral ulcers?

Not really.

Any urinary problems? Nope.

Any rashes? No.

Any chest pain? No.

Any shortness of breath? No.

In summary, Mr. Stern is a 29-year-old man who is seeking evaluation for a history of abdominal pain and diarrhea. The patient describes the first episode of pain about 15 months ago while on a trip in Central America. The pain disappeared and returned about 3 months ago. Today, the patient noticed red blood mixed with his stool and has sought medical evaluation. The patient describes the pain as crampy in nature and is relieved with defecation. He feels the pain mostly in his lower abdomen. He describes the pain as about a 5 or 7 on a scale of 10. He also has a bloating sensation in his abdomen most of the time. He does not have any nausea or vomiting. He denies being febrile. He has had a 5-pound weight loss in the past month. He saw a local physician about 3 weeks ago who gave him some antibiotic, which seemed to make things worse, and so he stopped taking the medication after 5 or 6 days. The symptoms have still persisted. He has had about 8 to 10 bowel movements a day for the past week. There has been some stringy mucus mixed in with the stool. The stools do not float. There is no lactose sensitivity. There is no apparent sensitivity to gluten (wheat, oat, barley, or rye products).

He is not taking any medications. He does not have any known allergies.

He is single and lives with his girlfriend of 8 months and always uses condoms for sexual protection. He uses marijuana about one or twice a month. He does not use any other recreational drugs. He works now as a legal clerk.

His mother is 54 years old and is in good health. His father died at age 56 from a sudden heart attack about 15 months ago. He has an older brother, age 31, who is in good health.

His review of systems is pertinent in that when he was 19 years old, he had iritis in his right eye, which was treated with steroids for 4 weeks and sunglasses. It improved in about 3 weeks. He also has a history of low back pain, which he attributes to bowling. The pain is intermittent and started when he was about 21 years old.

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