darkhorse
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A 39-year-old man comes to the office complaining of a 3-day history of severe abdominal pain and cramps that are relieved with bowel movements. He also reports loose, watery stools two to five times per day. He has had similar symptoms in the past and recalls the first incident being nearly 12 years ago. He tells you that he has been told that he has irritable bowel syndrome. He states that he has never had any other "tests" and was only prescribed various medications, some of which seemed to have helped. On examination, he appears to be in mild distress. His temperature is 38.3 C (101.0 F). He has mild guarding in his left lower quadrant but no rebound tenderness. He is tender to direct palpation in his left lower and left middle quadrants. The most appropriate next step in this patient's care is to
A. prescribe corticosteroids and see the patient in two weeks
B. prescribe loperamide and see the patient in two weeks
C. order a stool Gram stain and culture
D. schedule the patient for an immediate colonoscopy
E. schedule an immediate CT scan of the abdomen
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| doc_clotaire
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E------------diverticulitis------------CT scan
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| dr penicillin
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E
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| bax
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E
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| darkhorse
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| darkhorse
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the answer is correct.....but its not diverticulitis....any other thoughts
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| Kamsi
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Could it be Crohn's dx b/c of d diarrhea n abdominal findings
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| drdg
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Yes, from his age and timetable ( he had symptoms from 12 years ago), looks like he has Crohn's disease. He now had fever and tenderness in the left lower and left middle quadrants means he may have complications such as fistulization or abscess in that area. So schedule an immediate CT scan of the abdomen is necessary.
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| darkhorse
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The correct answer is E. Although this patient carries the diagnosis of irritable bowel syndrome, his presentation on this occasion has some elements that are concerning. In particular his fever and impressive abdominal examination coupled with his diarrhea and pain raise a high suspicion for an acute abdomen of some variety. This process may or may not be related to any existing abdominal pathology that this patient may have. He requires imaging of his abdomen to rule out an acute abdominal process such as abscess, pancreatitis, appendicitis, or even colitis.
Prescribing corticosteroids (choice A) or loperamide (choice B) and seeing the patient in two weeks presumes that this presentation has a similar etiology to his past presentations. Again, the impressive abdominal examination and fever makes the likelihood of this being related simply to irritable bowel syndrome very unlikely.
A stool Gram stain and culture (choice C) would be useful, but not more so than abdominal imaging.
Arranging for an immediate colonoscopy (choice D) is not correct for two reasons. First, the bowel preparation required for a good study doesn't make this test useful for acute situations. Secondly, the test limits visualization of possible etiologies to those that affect the large bowel.
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