CCS Interactive Case 5

Question 1

27 y/o F presenting to the office w/3 months alternating diarrhea and constipation, colicky abdominal pain relieved by defecation, 3 days non-bloody diarrhea containing mucus. No sick contacts, travel, weight loss, systemic symptoms

DDx

Answer 1

IBS, IBD, celiac disease, food allergies, lactose intolerance, infections (amebiasis or giardiasis), bowel obstruction, colon cancer

Question 2

First step?

Answer 2

Complete physical exam

Question 3

Next steps if exam is entirely normal, IBS is suspected, and absence of alarm symptoms (Lb loss, fevers, blood in stool)

Answer 3

Work-up to r/o organic disease while remaining prudent and cost-effective

CBC, BMP, ESR, TSH, FOBT, stool for O&P, white cells, culture, and 72 hour stool fat

[Further testing has poor diagnostic yield in suspected IBS and is not cost-effective]

Question 4

Work-up normal - management of IBS?

Answer 4

General:

• Diet modification (high fiber, lactose-free, avoid flatulence-producing foods)
• Reassurance, patient education, good physician-patient relationship
• Behavior therapy for symptoms associated w/stressors

Antispadmodics (dicyclomine, hyoscyamine) for pain
Antidiarrheals (loperamide)
TCAs (amitriptyline) and benzos (reserved for more severe cases)
Behavioral treatments (psychotherapy, biofeedback) for associated stressors

Question 5

Sequence

Answer 5

Complete physical exam
Orders (routine): CBC w/diff, BMP, TSH, FBOT, ESR, stool O&P, stool for WBC, stool bacterial culture, 72-hour stool fat, Pap smear
Location: home
Clock: schedule an appointment in 1 week
Location: office, patient arrives, request interval/follow-up
Order: lactose free diet, high fiber diet, loperamide, biofeedback, reassurance, relaxation, exercise, patient counseling, advise to drive with seat belt
Location:home
Clock: schedule an appointment in 2 weeks
Case ends
Final orders: None
Primary diagnosis; IBS