Question: Answer This Case Questions Chief Complaint“I Can’t Take The Pain And Diarrhea Anymore. I Thought I Could Make It Until I Got Home To See My Doctor But Today I Realized I Needed To See Someone.”HPIBonnie Smith Is A 32-year-old Woman Who Presents To The ED With The Chief Complaint Of A 1.5-week History Of Abdominal Pain Associated With Cramping, …

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Chief Complaint

“I can’t take the pain and diarrhea anymore. I thought I could makeit until I got home to see my doctor but today I realized I neededto see someone.”

HPI

Bonnie Smith is a 32-year-old woman who presents to the ED with thechief complaint of a 1.5-week history of abdominal pain associatedwith cramping, bloody diarrhea, and mucus that she states istypical of her UC flares. She states that she has been having aboutfour bloody bowel movements a day for most of the time that she hasbeen in our city on vacation, but today she was dizzy when shestood up; she did not have any symptoms while sitting or lyingdown. She has been here on vacation for almost 2 weeks and isscheduled to return home in 3 days. She has not traveled outsidethe country, been hospitalized, or received antibiotics recently.She was diagnosed with UC approximately 3 years ago and has hadapproximately one exacerbation a year that her physician hastreated with Pentasa capsules four times a day during eachexacerbation. Each time her symptoms have resolved with 4–6 weeksof therapy. She has refused maintenance therapy because she doesnot want to take a medication four times a day; it is not conduciveto her work and social life and she has refused rectal medicationsfor the same reason. Her last exacerbation was approximately 10months ago.

PMH

UC, diagnosed 3 years ago

Type 1 DM

FH

Mother has a history of CAD and lung CA; father has a history ofUC, S/P colectomy 18 years ago.

SH

Works as an office manager; lives with her fiancée; no children;denies tobacco use; drinks one to two glasses of wine every fewweeks; acknowledges marijuana use from 2005 to 2008 but states nonein the past 10 years

Meds

Insulin aspart via insulin pump; settings per endocrinology.

Vaccination history is unavailable.

All

NKDA

ROS

Negative for chest pain, SOB, dysuria, fever, chills, N/V,myalgias, arthralgias, polyuria, or recent allergic reaction.Positive for mild abdominal soreness, cramping, and intermittentbloody diarrhea with occasional urgency.

Physical Examination

Gen

A&O, pleasant, healthy-appearing Caucasian woman in NAD

VS

At 8 <small class=”uppercase” style=”font-size:12.800000190734863px;font-family:’Source Sans Pro’, sans-serif;”>AM</small>:

BP (lying down) 100/58 mm Hg, P 60 bpm

BP (standing) 80/40 mm Hg, P 75 bpm

RR 18/min, T 37.0°C

Wt 145 lb (66 kg), usual weight 150 lb (68 kg); Ht 5′7″ (170 cm);BMI 23.5 kg/m2

Skin

No lesions; warm, adequate turgor

HEENT

PERRLA; EOMI; mucous membranes without lesions or exudates; TMsintact

Lungs

CTA, no rales or rhonchi

CV

RRR, normal S1and S2;no S3,S4

Abd

Normal active BS, soft, nondistended; tender to deep palpation butno palpable mass; no liver or spleen enlargement; no reboundtenderness or guarding

Rect

Somewhat tender; no hemorrhoids, fissures, or lesions by anoscopy;heme (+) stool

MS/Ext

No CCE; pulses 2+; normal ROM; strength 5/5 bilaterally

Neuro

A&O × 3; CN II–XII intact; DTRs 2+

Labs

At 10:00 <small class=”uppercase” style=”font-size:12.800000190734863px;font-family:’Source Sans Pro’, sans-serif;”>AM</small>:

Fecal calprotectin: 160 mcg/g

Urinalysis

Color yellow; transparency clear; negative for protein, leukocyteesterase, nitrite, blood, ketones, RBCs, WBCs, and bilirubin; pH7.0; specific gravity 1.019

Assessment

Lower GI bleeding with a history of UC in a patient who hasdeclined maintenance therapy in the past

D/C with instructions to return to ED if symptoms worsen and tocontact PCP on return home

Clinical Course

The patient presents to her local PCP for follow-up 1 month afterher initial presentation to the ED. She states that her bowelmovements are “completely normal,” and she no longer has pain. Shestates that the symptoms started to resolve about 2 weeks after shestarted treatment. She has had no further complaints of weakness ordizziness. The repeat Hgb today is 12.9 g/dL.