Medical Student Sam Houston State College of Osteopathic Medicine Lufkin, Texas
Introduction: Utilizing a patient-centered approach to healthcare drives the osteopathic tenet of whole-person care. Physicians are trained not only to have clinical competence but to look beyond just current symptoms.
Case Study: A 28-year-old female with a past medical history of hypothyroidism, gastroparesis, chronic pancreatitis, generalized anxiety disorder, bipolar disorder and polysubstance use presented to the emergency department with intractable nausea, vomiting and abdominal pain beginning the morning before. She stated she had these episodes monthly, seemingly concomitantly with her menstrual cycle. As her cycle lightened, her symptoms lessened in severity. She was unable to keep down any food or liquids, and antiemetics such as ondansetron did not help. She attempted to premedicate with over-the-counter analgesics like acetaminophen and used her heating pad daily. She also noted occasional erythematous bumps on her fingers and palms. On exam, she was tachycardic, tachypneic, and had diffuse mottling on her abdomen. Upon review of her medical record, she had an extensive number of admissions to the hospital, as well as CT scans of the abdomen and pelvis, with the most recent showing a small hiatal hernia and mild mural thickening of the descending and sigmoid colons. Her mother had a history of celiac disease, Hashimoto’s thyroiditis, and Lyme disease. The patient stated she had never officially had bloodwork done to test for autoimmune gastrointestinal diseases. Upon admission, the patient’s labwork was found to have leukocytosis with a left shift and slight hypokalemia at 3.5. The following day, she was scheduled for an esophagogastroduodenoscopy, which was unremarkable, and a CT scan of the abdomen and pelvis showed fluid in the colon likely secondary to enteritis. Given her imaging results, stool cultures, urinalysis, and bloodwork monitoring thyroid function and hemoglobin A1c were ordered. Additionally, irritable bowel disease serum biomarkers such as C-reactive protein and erythrocyte sedimentation rate, perinuclear anti-neutrophil cytoplasmic antibodies, and anti-saccharomyces cerevisiae antibodies were ordered. She was later positive for anti-saccharomyces cerevisiae antibodies, indicating a strong likelihood for Crohn’s disease, and was treated with empiric IV methylprednisolone.
Discussion: This case demonstrates how strong clinical judgment and looking at the body as an integrated unit can drive forward answers for patients who previously thought there were none. In this case, every previous CT scan lacked a classical presentation for irritable bowel disease, but the patient’s signs and symptoms could have been clued into a proper diagnosis and long-term treatment sooner.
