CCS chron's disease
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]
- 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[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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