CCS chron's disease

Clinical Case: Diarrhea in a 28-Year-Old Female

History of Present Illness (HPI)

A 28-year-old female presents to the clinic with a chief complaint of diarrhea persisting for several days. She denies any associated fever, recent travel, or known exposure to infectious agents.

Physical Examination

• General: Alert, oriented, and in no acute distress.
• Vital Signs:
  • Temperature: 98.7°F
  • Pulse: 75 beats/min
  • Blood Pressure: 120/80 mmHg
  • Respiratory Rate: 18 breaths/min
  • Oxygen Saturation: 98% on room air

• Cardiovascular: Regular rhythm, no murmurs.
• Lungs: Clear to auscultation bilaterally.
• Abdomen: Soft, non-tender, non-distended, with no guarding or palpable masses. Bowel sounds present.
• Rectal: No visible external hemorrhoids, fissures, or masses. Guaiac positive.

Laboratory and Diagnostic Testing

• Complete Blood Count (CBC): Normal, with no leukocytosis.
• Chem7 (Basic Metabolic Panel): Within normal limits.
• Stool Guaiac Test: Positive for occult blood.
• Stool culture: No growth.
• Stool for ova and parasites: Negative.
• Colonoscopy: Mucosal inflammation noted. Biopsy performed.

Biopsy Results: Histologic examination reveals changes consistent with an inflammatory process. Findings are consistent with Crohn's disease.

Diagnosis

Crohn's Disease: A chronic inflammatory bowel disease affecting any part of the GI tract.

Management

• Medical Management:
  • Mesalamine: To reduce inflammation.
  • Antidiarrheal medications: To manage symptomatic diarrhea.

• Follow-up:
  • The patient was asked to return to the clinic for a re-evaluation in a couple of days. Upon reassessment, the patient reported significant improvement in diarrhea and overall felt better.
  • Further follow-up was scheduled in two weeks to assess the ongoing management and response to medications.

Note: Management of Crohn's disease is complex and often requires a combination of medications, nutritional support, and sometimes surgical intervention. It's essential to individualize the treatment plan based on the patient's presentation and disease severity. Regular monitoring and follow-up are crucial for these patients.

USMLE Wiki

• Usmle Step1 | Usmle Step2 | Usmle Step3

• List of Cases > CSA&CS | Step3CCS

Popular: Usmle Step 3 CCS | Usmle Step 3 CCS cases part 2 - over 70 solved cases

Asters Notes > Asters Notes I | Asters Notes II | Asters Notes III

Other resources: Usmle Q Banks | Residency Wiki

List of patient cases