Unexplained Diarrhea and Weight Loss: What's going on? | Case Study

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.

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Unexplained Diarrhea and Weight Loss: What's going on? | Case Study

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?

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.

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SafetyNurse1968

About SafetyNurse1968, BSN, MSN, PhD

Patient Safety Columnist / Educator

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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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?

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

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Specializes in Occupational health, Corrections, PACU.

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?

 

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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? 

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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? 

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

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Specializes in Hospice.

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

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Specializes in Cardiac.

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 

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Specializes in Community health.

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?

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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! 

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Specializes in kids.

Was there any hardware planted in the  jaw surgery?

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