Chief Complaint
“I’m having terrible abdominal pain! I’m also having diarrhea that sometimes appears black.”
History of Present Illness
Ms. A.C is a 21 yo white female presenting with moderate crampy abdominal pain and intermittent diarrhea involving melena stools that started 5 days ago. She arrived feeling fatigued with a low grade fever, loss of appetite, and unintentional weight loss of 15 pounds in the past month and a half.
Past Medical History
- Asthma, age 8 years
- Tonsillectomy, age 10 years
- Appendicitis and appendectomy, age 14 years
- Complicated Salmonella food poisoning, age 18 years
Pertinent Family History
- Cholelithiasis (mother) at age 36 years
- Rheumatoid arthritis (mother) at age 42 years
- Diverticulitis (father) at age 44 years
- Osteoporosis (paternal grandmother) at age 67 years
Social History
- Current smoker, 0.5 packs a day beginning at 18: 1.5 pack years
- Social drinker: 3 drinks a week with friends
- Eats a diet high in saturated fat and sugar
- Reports exercise is walking to work, half mile round trip 5 days a week
Allergies
- Latex
- Seasonal allergies: hay fever
- Cat dander
Medications
- Centrum Women’s Multivitamin
- Phillips Colon Health Probiotics
- Nature Made Echinacea for the past three days for flu like symptoms
- Ethinyl Estradiol Levonorgestrel (Seasonale) birth control pill 0.15 mg/0.03 mg QD
Focused Physical Exam
- Buccal ulcers: two right and one left
- Skin tags: lower left jaw line, right side of neck, and anus
- Eczema on elbows bilaterally and forehead
- Abdominal tenderness in right lower quadrant
- Small palpable mass in the right lower quadrant