Biographical Information
Svetlana is a 16 year old cisgender girl presenting to your primary care clinic with chief complaints of fatigue and abdominal pain. She has no significant surgical or medical history, and her last menstrual period was three months ago. Svetlana is of Ashkenazi Jewish descent and has a father with Ulcerative Colitis and a maternal grandmother with psoriasis.
Review of Systems
WNL: Neurological, Respiratory, Endocrine, Genitourinary, Cardiovascular, and Musculoskeletal
General: Fatigue
Integumentary: No symptoms reported; thin, fine body hair and inelastic skin turgor observed by provider during assessment
HEENT: Ulcerations in mouth and vision changes reported
GI: Painful diarrhea with extreme urgency accompanied by pain in RLQ
Reproductive: Amenorrhea for the last 3 months (menarche 4 years ago, regular cycle before now)
Lab Results
CBC
- WBC count of 20,000
- Hgb 9.5%
- Hct 25%
- Ferritin 10 NG/dL
- RBC morphology: Macrocytic and hypochromic (Possibly indicative of Vitamin B12 and iron deficiency)
Stool Sample
- Negative for parasites and ova
- Positive for occult blood
Scope Results
- Skip lesions throughout intestines, with worst disease found in terminal ileum
- Transmural inflammation with characteristic cobblestone mucosa