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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
What information do you need to help this patient with a diagnosis?
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.
About SafetyNurse1968, BSN, MSN, PhD
Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com.
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