Internal Medicine

24 yo male presents with crampy abdominal pain

Reda Jaber on Dec 19, 2013

HPI: A 24 yo male presents to a community clinic with a 3 month history of crampy abdominal pain that gets better with bowel movements. He also complains of diarrhea, as well as loss of weight and appetite.

PMH:
- Depression
- Lower Back Pain

PSH: none

Medications:
- Cymbalta 20mg BID
- Acetaminophen PRN

SH: Patient is a student at the university, and he lives with two roommates. Denies tobacco or illicit drug use. Drinks occasionally on weekends.

FH: Mother and brother with Crohn's disease. Cousin with Ulcerative Colitis

 

  • Temp  37 C
  • HR  75
  • BP  110/70
  • RR  16
  • O2  99% on Room Air

Physical Exam:
General: Resting comfortably in no acute distress.
HEENT: EOMI, MMM.  No oral lesions, no pharyngeal exudates.
Pulm: CTAB, no wheezing, no crackles.
CV: RRR, no m/r/g.
Abd: Soft, mildy distended, mild tenderness to palpation diffusely. +BS in all 4 quadrants.
Neuro: No focal deficits.

What is your differential diagnosis at this point?
(See next page)

HPI: A 24 yo male presents to a community clinic with a 3 month history of crampy abdominal pain that gets better with bowel movements. He also complains of diarrhea, as well as loss of weight and appetite.

PMH:
- Depression
- Lower Back Pain

PSH: none

Medications:
- Cymbalta 20mg BID
- Acetaminophen PRN

SH: Patient is a student at the university, and he lives with two roommates. Denies tobacco or illicit drug use. Drinks occasionally on weekends.

FH: Mother and brother with Crohn's disease. Cousin with Ulcerative Colitis

 

  • Temp  37 C
  • HR  75
  • BP  110/70
  • RR  16
  • O2  99% on Room Air

Physical Exam:
General: Resting comfortably in no acute distress.
HEENT: EOMI, MMM.  No oral lesions, no pharyngeal exudates.
Pulm: CTAB, no wheezing, no crackles.
CV: RRR, no m/r/g.
Abd: Soft, mildy distended, mild tenderness to palpation diffusely. +BS in all 4 quadrants.
Neuro: No focal deficits.

What is your differential diagnosis at this point?
(See next page)

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