Reference no: EM133845362

Question

A 24-year-old male presents to the urgent care clinic with complaints of rectal bleeding and weakness. He reports noticing bright red blood in his stools 5 days ago, and he is having more frequent bowel movements, "5 or 6 a day", with diarrhea. He states that urges to move his bowels have a rapid onset, but there has been no incontinence. He has been weak for 2 days. He has not traveled outside of the city, been hospitalized or received antibiotics recently.

PMHx: chronic sinus infections X 10 years, VSD at birth repaired at age 1. Family Hx: strong positive family history of autoimmune disease on maternal side, mother with SLE and maternal grandmother had Graves disease. Medications: none. NKDA.

Social Hx: college graduate, recently discharged from military service, works in IT at local university. Denies tobacco or illicit drugs. Social alcohol use 1-3 times/month.

Review of Systems: denies lightheadedness while sitting or rising, denies N/V, visual changes, eye pain, abdominal distension or gas, or joint pain. Does report melaise, mild abdominal cramping, loss of appetite, and weight loss.

Physical Exam and VS: BP 120/75, P 93, R 30, T 99.40, SaO2 95% on RA, Ht. 70 inches, Wt. 161 lbs (down 4 pounds, patient reports).

Skin/Neuro/HEENT: alert, oriented, pleasant and appropriate dress and speech for situation. All reflexes intact. Skin is pale, good turgor, PERRLA, EOMI, oropharynx/nose/ears clear.

Chest: breath sounds clear. Cardiac: RRR, no extra heart sounds.

Abdomen/Rectal: normoactive BS, soft, nontender,nondistended, no hepatosplenomegaly, no bruits. Digital rectal exam: tender, no hemorrhoids or other lesions, (+) heme in stool.

Laboratory results: Na, K, Cl, BUN, Cr all within normal limits. Hb 10.8 g/dL, Hct 36%, WBC 9,4000/mm3 , plt 315,000/mm3 , ESR 24 mm/hr, hs-CRP 15 mg/L, AST 33 IU/L, ALT 41 IU/L, T bilirubin 0.9 mg/dL, PT 11.3 sec, Alb 3.1 g/dL.

Answer the following questions based on the provided information:

1. Why is it important to ask about recent travel, hospitalization and antibiotic use for this particular patient?

2. What is the significance of the patient's family history?

3. What laboratory results are abnormal and what is the significance of each abnormal?

4. What disease process is most likely, based on the information provided?

5. What additional testing/diagnostics should be ordered and what would be the expected findings based on your answer of #4?