Unexplained Diarrhea and Weight Loss: What’s going on? | Case Study Nurses Week Contest

Updated | Published
by SafetyNurse1968 SafetyNurse1968, ADN, BSN, MSN, PhD

Specializes in Oncology, Home Health, Patient Safety. Has 20 years experience.

A new case study in which the patient, a 28 y/o white female presents to a primary care clinic complaining of recurrent diarrhea. She first experienced diarrhea three years ago after undergoing reconstructive jaw surgery following a motor vehicle accident.

What is going on with this young woman?

Unexplained Diarrhea and Weight Loss: What’s going on? | Case Study Nurses Week Contest

Month-Long Nurses Week Celebration Starts Today! Nurses Week Contest #1

Test your knowledge and clinical investigative skills in trying to diagnose what is going on with the patient who has presented with Unexplained Diarrhea and Weight Loss. Can you come up with the right diagnosis? The winning participant will win $100 Amazon Gift Card courtesy of University of Maryland!

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Chief Complaint

“I’ve had diarrhea now for 3 years and I keep losing weight.” Patient also complains of a racing heart, headache and dizziness.

History of Present Illness

Diarrhea began a few days after the patient had reconstructive jaw surgery. The patient states that extensive evaluation at two institutions failed to reveal a cause of her illness. She states, “My stool weighed 1008 grams each day (normal weight for women is 87 +/- 8 g/day). The diarrhea was secretory in nature without steatorrhea. They did biopsies, x-rays, upper and lower endoscopy and they found nothing…no melanosis coli, ruled out microscopic colitis, small bowel disease…and my serum gastrin and VIP were within normal limits. I also had no pathogens in my stool culture.”  About two years after onset of diarrhea, she went to another medical center where diagnostic tests were repeated with no diagnosis. After a colonoscopy she had severe bleeding and required multiple units of blood and her weight dropped to 108 pounds. At that time total parenteral nutrition was begun until she healed.

General Appearance

Patient appears thin and pale. She has a thick notebook full of notes which she refers to when discussing her medical history. She has to be interrupted repeatedly to get pertinent information, and she smiles and giggles occasionally while talking about her illness.

Past Medical History

No significant medical or psychiatric history other than fractured right jaw after MVA three years ago.

Family History

Patient has been married for four years. Mother is 65 with hypertension and obesity. Father is 72 with CAD and hypercholesterolemia. Patient has no siblings. She states, “My father abused me and my mother and I don’t talk to him. He used to hit us. My homelife was terrible.”

Social History

The patient lives with her husband. She smokes, stating, “only 1 or 2 a day” and drinks wine once or twice a week. Denies recreational drug use. She is enrolled in an online graduate school program and studying biology. “My husband works all day, so I’m alone a lot. I’d really like to go to medical school, but I’m just not sure I could do it because of my health.”

Medications

Denies taking any medications

Allergies

Penicillin, radiocontrast, aspirin

Review of Systems

Only abnormal values presented

Skin: Pale, dry, scarring on right jawline, right elbow and left knee.

Vital Signs

  • BP 125/70 sitting, LA
  • HR 92
  • RR 20
  • T 98.7o F
  • HT 5’6”
  • WT 110 lbs
  • BMI 17.8

What information do you need to help this patient with a diagnosis?

REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.

This contest is sponsored by University of Maryland.

University of Maryland Earn your MSN online from anywhere: Join one of the nation’s top-ranked Nursing Informatics or Health Services Leadership and Management programs. Pay in-state tuition in 15 states, and we’ll arrange your practicum placement for you. Become a leader in the conceptualization, design, and research of digital information systems or in nursing leader and management, business, or education. Full-time and part-time options available.

Disclaimer: These case studies are presented for learning purposes only and with full understanding that it is outside the scope of practice for a nurse to make a medical diagnosis. When participating, assume that a licensed healthcare provider is making the actual diagnosis, ordering all the tests and interpreting the results. You are looking at the case retrospectively to learn from the data presented – the idea is to increase your knowledge so you can sharpen your assessment and teaching skills.

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is also a mother of four who loves to write so much that she would probably starve if her phone didn’t remind her to take a break. Her work experiences as a hospital nurse make it easy to skip using the bathroom to get in just a few more minutes on the computer. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com. You can also get free Continuing Education at www.safetyfirstnursing.com.

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28 Comment(s)

swirt1958

swirt1958

Has 40 years experience. 9 Posts

Abdominal complaints, bloating or explosive flatulence?

Is there any pattern to the diarrhea episodes, such 30 minutes after a meal, or at night when lying down?

Has patient completed a food diary? if so, are there any patterns, such as diarrhea after fatty meals?

 

 

d'cm

d'cm

282 Posts

Has the thyroid been fully evaluated by imaging and blood work?

katkonk, BSN, RN

Specializes in Occupational health, Corrections, PACU. Has 25 years experience. 400 Posts

Did she begin to use laxatives after her jaw procedure, perhaps to counteract constipation due to opioid pain medications? Is there a history of long term use/abuse of laxatives at any time?  

Has a Fecal microbiota transplantation (FMT) treatment been attempted as part of her care?

Has a sensitive gut diet been tried to see if symptoms are reduced, minimized, or eliminated?

Has she had a psychiatric assessment?

 

guest1163268

guest1163268

2,215 Posts

e. She has a thick notebook full of notes which she refers to when discussing her medical history.

* is there an obsessive component or memory loss? 

She has to be interrupted repeatedly to get pertinent information, and she smiles and giggles occasionally while talking about her illness.

* Why does she have to be interrupted.... Tangential thoughts? 

* Why the giggles?.... Inappropriate?.... Voices?.... Personality? She likes staying at home. 

Any infection component.... Worms etc? 

Colonoscopy... Severe bleeding... Seems significant? Why? 

d'cm

d'cm

282 Posts

to build on Curious1997: The medical history appears to be entirely "per the patient", do we have any actual medical records to verify her statements? 

JKL33

6,321 Posts

Random curiosity: What was her weight status prior to the accident and subsequent jaw surgery?

cardiacfreak

cardiacfreak, ADN

Specializes in Hospice. 742 Posts

Any changes in taste or smell, poor appetite, changes in her nails, hair, or skin?

9kidsmomRN

9kidsmomRN

Specializes in Cardiac. Has 31 years experience. 69 Posts

No pathogens in stool, any foreign travel?notebooks-a curious finding. Inappropriate giggling. Wants to be an MD.... ?

agree with d’cm: check pt’s medical history against her statements 

CommunityRNBSN

CommunityRNBSN, BSN, RN

Specializes in Community health. Has 4 years experience. 831 Posts

Knowing the weight of her stools (this is given as per her recollection) is bizarre and speaks to obsession with health. Psych consult needed. 
 

scarring noted on elbow and knee. What type of scars?  Surgical?  Self-harm?

guest1163268

guest1163268

2,215 Posts

18 minutes ago, CommunityRNBSN said:

Knowing the weight of her stools (this is given as per her recollection) is bizarre and speaks to obsession with health. Psych consult needed. 
 

scarring noted on elbow and knee. What type of scars?  Surgical?  Self-harm?

I'm really hoping this is medical. It would make it so interesting! 

I just wonder though how significant the abuse from her father has affected her mental health? 

It would be really far out if a histrionic reaction could be manifested so physically! 

Great case! 

Edited by Curious1997

NutmeggeRN, BSN

Specializes in kids. Has 39 years experience. 8 Articles; 4,533 Posts

Was there any hardware planted in the  jaw surgery?