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Discussion: Case Study on a Patient with Crohn’s Disease

Discussion: Case Study on a Patient with Crohn’s Disease

 

Case Overview

I will discuss a case scenario of a white female patient, 18-years of age who presents with a history of recurrent abdominal pain for two weeks. She also has a history of intermittent cramping, low-grade fever, diarrhea, and poor appetite. Besides, she reports smoking half a packet per day in the last years but denies the use of alcohol and illegal drugs. Furthermore, the patient has a history of Crohn’s disease.

Differential Diagnosis

Crohn’s Disease (CD) Flares

 Crohn’s disease is a chronic disease that has a high prevalence in children and adolescents. It is caused by inflammation of the gastrointestinal tract and characterized by gastrointestinal symptoms, including abdominal pain, diarrhea, and rectal bleeding (Torres, Mehandru, Colombel & Peyrin-Biroulet, 2017). The body temperature slightly elevates as a result of the production of inflammatory mediators to fight bacterial infection. A CD flare is the recurrence of symptoms whereby recurring symptoms include diarrhea, abdominal pain, and lack of appetite, fever, weight loss, and fatigue. Flares are triggered by smoking, NSAIDs, stress, spicy and fatty foods, and missing medications (Torres et al., 2017). CD flares is the most probable diagnosis as per the patient’s history of Crohn’s disease. Besides, the patient had positive symptoms of low-grade fever, abdominal pain, diarrhea, and poor appetite. It is highly possible that the patient was experiencing CD flares that could have been triggered by smoking.

Amebic Colitis

The condition is of gradual onset, and the symptoms present for 1-2 weeks. The most common presenting symptom is diarrhea, which is either bloody or watery (Patel & Cello, 2016). Amebic colitis also manifests with abdominal pain with a cramping characteristic, fever, loss of appetite, weight loss, and in some patients, rectal bleeding. It is a likely diagnosis based on positive patient’s symptoms of abdominal pain lasting two weeks, fever, diarrhea, and a poor appetite.

Clostridium Difficile Colitis

 The condition results from colonization of the large intestine by C.difficile due to an alteration of the normal flora. A proliferation of the C.difficile results in the bacteria, causing an inflammatory response in the colon by releasing toxins that inflame the mucosal layer (Patel & Cello, 2016). C.difficile colitis presents with moderate watery diarrhea, cramping abdominal pain, fever loss of appetite, and general body weakness. It is a probable diagnosis based on positive symptoms of abdominal cramping, fever, poor appetite, and diarrhea.

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Beneficial Physical Exam Findings

  1. Lower Abdominal Tenderness – Generalized abdominal tenderness is suggestive of generalized peritonitis while a diffuse
    Discussion Case Study on a Patient with Crohn’s Disease

    Discussion Case Study on a Patient with Crohn’s Disease

    tenderness is mostly present in Crohn’s Disease (Feuerstein & Cheifetz, 2017). On the lower right quadrant, tenderness on palpation could be a sign of inflammation in the appendix, caecum, diverticulum or a perforated malignant tumor. Left lower quadrant tenderness is mostly due to inflammation of the sigmoid colon.

  2. Abdominal Masses – Presence of masses on palpation in the lower abdominal quadrants could be a result of inflammation or benign and malignant tumors (Patel & Cello, 2016). Masses in the right lower quadrant suggest inflammation in the appendix or carcinoma of the caecum. On the left lower quadrant, palpable masses could be a result of diverticulitis or sigmoid colon carcinoma.
  3. Rebound tenderness: This is indicative of infection or inflammation of the appendix, colon, pancreas, and pelvic inflammatory disease.
  4. Digital Rectal Exam Findings. Positive findings of an anal abscess, fistula, and fissures are a characteristic of Crohn’s disease.

Diagnostic Tests

  1. White Blood Cells Count (WBC). A high level of WBC count indicates the presence of infection. It is also common in inflammatory diseases of the colon.
  2. Stool studies: These will include a lab test for stool culture to help in detecting and identifying the presence of pathogenic bacteria and evaluating the proliferation of the normal bacterial flora such as C.difficile, in the lower gut. Stool for ova and cyst to help detect the presence of parasites such as ameba and giardia lamblia.
  3. Barium enema: This will be useful to detect colon abnormalities such as mucosal ulcers, edema, partial obstruction, and polyps.

Treatment Plan

  1. Medications
  • Sulfasalazine suppresses flares and for maintaining remission.
  • Flagyl 500mg TDS for 7 days; to kill protozoa and bacteria.
  • Hydrocortisone 10mg BD for 3 days; to inhibit inflammation.
  • Loperamide 4mg QID for 3 days; to relieve diarrhea.
  1. Health education

            I will advise the patient on cessation of smoking since tobacco increases the frequency and severity of CD flares (Torres et al., 2017). Besides, I will offer health education on stress-management strategies to help in reducing recurrence since CD flares are triggered by stress. Medication adherence on the prescribed drugs will also be emphasized to avoid flare-ups. In addition, nutritional counseling will be offered on taking a healthy diet and eating small meals containing soft foods when having flares (Feuerstein & Cheifetz, 2017). Lastly, I will advise the patient to avoid spicy and fried foods and NSAIDs such as aspirin and diclofenac to prevent irritating the gut mucosal and aggravating the symptoms.

Engaging in regular physical activity such as swimming, jogging, and running as it helps improve the body’s immune system and avoid recurrence of inflammation.

Follow-up

I will schedule a follow-up visit after two weeks to evaluate progress, assess for comorbid conditions, and treat presenting symptoms.

An 18-year-old white female presents to your clinic today with a two-week history of intermittent abdominal pain. She also is positive for periodic cramping and diarrhea as well as low-grade fever. She also notes reduced appetite. She notes that She admits smoking ½ PPD for the last two years. Denies any illegal drug or alcohol use. Does note a positive history of Crohn\’s Disease. Based on the information provided answer the following questions:

What are the top 3 differentials you would consider with the presumptive final diagnosis listed first?
What focused on physical exam findings would be beneficial to know?
What diagnostic testing needs to be completed if any to confirm the diagnosis?
Using evidence-based treatment guidelines note a treatment plan.

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