Chief Complaint (CC)
“My stomach hurts and I’ve been having diarrhea”
History of Present Illness
L.S. is a 16 Y.O. Caucasian male who was referred to the gastrointestinal (GI) clinic by his pediatrician. The patient complains of abdominal pain, diarrhea, and fatigue for the past two months. The patient’s mother reports that he has not been eating and has been losing weight. She states that “he can be a picky eater at times, but even when I make something he loves, he doesn’t want to eat it”. L.S. says that at school, he makes frequent trips to the restroom during multiple classes, especially in his first class of the day and after lunch. He also says that “when I hang out with my friends at their house or at the mall, I always have to know where the bathroom is. I spend more time worrying about making it to the bathroom than having fun”. He denies any nausea or vomiting with his symptoms. The patient’s family is driving to Georgia to spend winter break with relatives and they want to help L.S. to manage his symptoms.
Past Medical History
- Perianal abscess – 2015
- Generalized anxiety disorder (GAD) – 2013
Family History
- Father – 57 years old – healthy
- Mother – 56 years old – diagnosed with Crohn’s disease (age 39)
- Brother – 20 years old – diagnosed with Crohn’s disease (age 20)
Social History
- High school student – A-B student
- No past or present alcohol or drug use
- No history of smoking
Allergies
- Bactrim – skin rash
Medications
- Polyethylene glycol 3350 (MiraLAX) – 17g/day – as needed for occasional constipation
- Ibuprofen – 400 mg – for abdominal pain
Focused Physical Exam
- Weight: 115 lb – decrease from 130 lb at last physical (15 lb weight loss)
- Tenderness in abdomen
- No reported nausea or vomiting
- Anal fissure
- Small amount of bright red blood
- When asked about bowel movements, patient says “it hurts to go to the bathroom”
- Reddened nodules on lower legs bilaterally
- Patient describes them as “painful”