Episodic Case Write-Up
Patient Initials: J.S. Age: 38 years old Sex: Male Race: White
- Chief Complaint
“I have diarrhea that occurs together with abdominal pain. I also have constipation.”
- History of Present Illness (HPI)
J.S. is a 38-year-old white male patient who has come to the clinic seeking medical assistance. The patient’s chief complaint is diarrhea that occurs together with constipation and abdominal pain. He indicates that the symptoms started 7 days ago. J.S. does not associate his symptoms with any food or drug consumed recently. He further states that he had his last physical exam in June 2021.
Location: Lower abdomen.
Quality: Persistent pain
Quantity or severity: The pain is severe. It can be rated at 5/10 on the pain scale
Timing: 7 days ago
Setting: Constant
Aggravating or relieving factors: Unknown
Associated manifestations: Constipation, diarrhea, and fatigue
III. Past medical history (PHx)
- Childhood illnesses
J.S.’s medical records show that he has never been hospitalized before. However, he was diagnosed with malaria and a cold during childhood which were successfully treated without hospitalization.
- Immunizations
According to J.S.’s immunization records, he received all immunizations as scheduled during childhood and adolescent years. He lastly received his tetanus booster when he was 30 years old. He has his last influenza vaccine when he was 20 years old. J.S. has not received any COVID-19 vaccine.
- Adult Illnesses
He denies serious medical diagnoses during adulthood.
- Operations
J.S. has not undergone any operation before.
- Allergies
He denies drug or food allergy.
- Medications
None.
- Complimentary treatments
None.
- Family history
J.S. is the third born child in a family of five children. His father died from natural causes three years ago at the age of 77 years. His mother is alive and without a serios medical diagnosis. His four siblings are well. J.S. did not have an opportunity to interact with maternal and paternal grandparents and does not even know their causes of death.
- Social history
J.S. is happily married with one wife and three children. He is an engineering currently employed in a nearby construction company. His wife is also employed as a nurse at a city hospital. J.S. denies consuming cigarettes. However, he occasionally consumes alcohol when he goes out with friends.
- Review of Systems
General: Denies fever or nausea. Reports constipation. Denies abnormal change on weight.
Skin: Denies redness, rashes, or pruritus. Denies brittle nails.
HEENT:
Head: Denies a headache. Denies physical head injury.
Eyes: Denies vision issues. Denies a history of cataracts.
Ears: Does not report pain in the ears. Denies hearing loss.
Nose: Denies nasal discharge, nasal stuffiness, or changes in smelling abilities.
Throat: Denies mouth ulcers or hoarseness of the throat.
Neck: No neck pain or swelling reported. Does not report goiter.
Lymphatics: Denies swollen lymph nodes.
Breasts: Denies pain or discharge in the breasts.
Pulmonary: Denies a cough, breathing difficulties, or hemoptysis. Denies a history of pneumonia or tuberculosis.
Cardiovascular: Does not report shortness of breath, heart murmurs, or chest pain. Denies a history of high blood pressure or cardiovascular disease.
Gastrointestinal: Increase in bowel movement reported. Reports abdominal pain and diarrhea. Denies vomiting, reports constipation, and denies a history of gallbladder problems.
Urogenital: Does not report hematuria. Denies a reduction in the volume of urine. Denies a history of nocturia, urinary tract infections or kidney stones. Does not report penis pain. Denies a history of sexually-transmitted disease.
Musculoskeletal: Does not report swelling of the joints. Denies tenderness of the joints or a history of fracture.
Neurologic: No seizures, tremors, or numbness of the limbs reported. Does not report memory loss, dizziness, or a headache. Reports fatigue or tiredness.
Psychiatric: Does not report anxiety, insomnia, depression, or a history of suicidal ideation.
Endocrine: Denies excessive urination, excessive sweating, or excessive thirst. Does not report cold or heat intolerance.
Hematologic: J.S. does not report uncontrolled bleeding or easy bruising. He also denies a history of hematologic disorders like sickle-cell disease or anemia.
VII. Physical examination
Vital signs: Temperature: 36.5 degrees Celsius, Blood pressure: 118/80, Heart rate: 91 beats per minute, weight: 160.8 pounds, Respiratory rate: 20 breaths per minute.
General appearance: J.S. is able to remain still. He is alert and attentive. He looks tired. J.S. is properly oriented to place, time, and person.
Skin: Warm and smooth with no lesions or sores. Cyanosis is absent on the nail beds.
HEENT:
Head: Normocephalic. Lacks evidence of trauma. No scarring, alopecia, or hair thinning.
Eyes: Conjunctivae are clear. Hemorrhage or exudates are absent. Non-opacified cornea, discharge absent, non-icteric sclerae absent. Visual acuity is 20/20.
Ears: No edema or tenderness on the ear canal or external ear. No evidence of discharge or blockage. Pale grey tympanic membrane.
Nose: Nasal septum present midline. Pink, moist, and hairy nasal mucosa. Turbinates are not enlarged.
Throat: Absence of ulcers, lesions, or sores in the oral mucosa. Evidence of good dentition. No tonsillar exudates. No evidence of erythema in the throat.
Neck: Unusual pulsations or masses absent. Palpable thyroid. Trachea visible in the midline position.
Nodes: Absence of inguinal swelling.
Breasts: Absence of masses, tenderness, or discharge on the breasts.
Chest: Auscultation does not reveal evidence of crackles, wheezes, or rhonchi. Inspection does not reveal evidence of deformities. Fremitus absent after palpation.
Heart: PMI is visible. Normal heart rate. No heaves. S1, S2 noted. Absence of edema. Capillary refill less than 3 seconds.
Abdomen: Scars absent. Abdominal tenderness observed. Evidence of bowel sounds. Abdominal distention and bloating present.
Musculoskeletal including back/spine: No curvature of the spine. No deformities. Normal gait. Absence of tremor. Joint tenderness or swelling absent.
Genitalia/Rectal: Lesions absent on external genitalia. Pubic hair present. Absence of vaginal discharge or inflammation.
Neurologic:
Mental status: J.S. is attentive and able to concentrate. He has a normal speech. No evidence of memory loss.
Cranial nerves: Evidence of full EOM’s on crania nerves II-IX. Visual fields present.
Motor: Absence of muscle rigidity. Good balance observed. All joints have a muscle strength of 5/5.
Sensory: Sensitivity confirmed in upper and lower limbs. 2+ reflexes.
- Differential diagnosis
- Irritable Bowel Syndrome (primary diagnosis) (Camilleri, 2019)
- Lactose Intolerance (Catanzaro et al., 2021)
- Celiac disease (Caio et al., 2019)
Rationale for Primary Diagnosis
The symptoms displayed by J.S. closely resemble those of irritable bowel syndrome. The primary symptoms commonly displayed by patients with irritable bowel syndrome are abdominal pain, diarrhea, and constipation (Camilleri, 2019). These symptoms must be present for at least three days for disease presence to be confirmed. Irritable bowel syndrome must not be triggered by food or drug consumed recently. Severe abdominal pain that occurs together with diarrhea and constipation confirms that J.S. has irritable bowel syndrome. Physical exam results associated with the disease include abdominal tenderness, bloating, bowel sounds, and a distended abdomen (Bickley, 2019). The healthcare professional can conduct additional tests to confirm or rule out the presence of irritable bowel syndrome.
References
Bickley, L. (2018). Bates guide to physical examination and history taking (12th ed.). Philadelphia, PA: Wolters Kluwer.
Caio, G., Volta, U., Sapone, A., Leffler, D., Giorgio, R., Catassi, C. & Fasano, A. (2019). Celiac disease: a comprehensive current review. BMC Medicine, 17, 142. https://doi.org/10.1186/s12916-019-1380-z
Camilleri, M. (2021). Diagnosis and treatment of irritable bowel syndrome: A review. JAMA, 325(9):865-877. doi: 10.1001/jama.2020.22532.
Catanzaro, R., Sciuto, M. & Marotta, F. (2021). Lactose intolerance: old and new knowledge on pathophysiological mechanisms, diagnosis, and treatment. SN Comprehensive Clinical Medicine, 3, 499–509. https://doi.org/10.1007/s42399-021-00792-9.