CCS chron's disease

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Clinical Case: Diarrhea in a 28-Year-Old Female[edit | edit source]

History of Present Illness (HPI)[edit | edit source]

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[edit | edit source]

  • 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[edit | edit source]

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

Diagnosis[edit | edit source]

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

Management[edit | edit source]

  • 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.


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Contributors: Prab R. Tumpati, MD