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A 78-year-old man with fever and diarrhea - 10 Point - [SOLVED]


A 78-year-old man has a 10-day history of low-grade fever and diarrhea with as many as six bowel movements daily. He also has nocturnal diarrhea and develops abdominal pain before defecating. The patient has congestive heart failure. Current medications are enalapril, furosemide, and atenolol.

On physical examination, temperature is 38.2 °C (100.8 °F), pulse rate is 90/min, and blood pressure is 110/70 mm Hg. Diffuse abdominal tenderness is present. Rectal examination is normal; there is no stool in the rectal vault.

Laboratory Studies
Hemoglobin: 17 g/dL (170 g/L)
Leukocyte count: 12,000/µL (12 × 109/L)
Platelet count: 380,000/µL (380 × 109/L)
Stool cultures: No growth of pathogens
Stool assay for Entamoeba histolytica antigen Negative

In addition to volume resuscitation with intravenous fluids, which of the following is the most appropriate next step in managing this patient?
a. Stool examination for fecal leukocytes
b. Stool examination for ova and parasites
c. 48-Hour fecal fat determination
d. Upper endoscopy with duodenal aspirates
e. Flexible sigmoidoscopy with biopsies

Which is most likely Diagnosis:
a. Acute diverticulitis
b. Irritable bowel syndrome
c. Inflammatory bowel disease
d. Malabsorbation
e. Shigellosis or Salmonellosis


Case Submitted by Dr Ibrahim Al-Mahdi ( 1, 2 )

for each alternative that you choose its better to explain, one case will have 2 winners
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25 comments:

  1. This comment has been removed by the author.

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  2. 1. e. Flexible sigmoidoscopy with biopsies
    2. b. Irritable bowel syndrome

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  3. 1. e. Flexible sigmoidoscopy with biopsies
    2. c. Inflammatory bowel disease

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  4. You Sould explain your answer .. It's better to

    be lucky to win ...


    Dr.Ibrahim Al-Mahdi

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  5. 1.e since no other of the above mentioned investigations which can explain the cause. in a just leukocytes cant prone any thing significant , in b)the man is perfect with hb count so no ova or cyst c)dont think its any malabsorption since history of complaint is 10 days.
    2. think its b

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  6. diarrhea + fever + abdominal pain and

    leukocytosis should be aclue to something ..

    What is it ?

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  7. e. Flexible sigmoidoscopy with biopsies


    c. Inflammatory bowel disease

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  8. as there is afever so it most propaply inflammatory & IBS not assiociated with fever

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  9. b. Stool examination for ova and parasites-


    b. In This Patient , The Major complains are:low-grade fever and diarrhea with as many as six bowel movements daily, nocturnal diarrhea & abdominal pain before defecating.These are the suspected symptoms for Irritable bowel syndrome.

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  10. What relation between ova and Irritable bowel

    syndrome ? Explain more

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  11. flexible sigmoidoscopy &biopsy and ac diveticulitis in view of pain,diarrhea low grade fever

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  12. diveticulitis in

    view of pain,diarrhea

    low grade fever and leukocytosis but our case

    not showing that ! Leukocyte count:

    12,000/µL (12 × 109/L)

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  13. The inflammatory bowel disease can create ulceration and pain, with general tenderness, Crohn`s disease can even cause the perforation of the wall , leading to acute peritonitis..i would think first of diverticulitis because of the age of this patient, but there is not leukocytosis... so i believe first is e. Flexible sigmoidoscopy with biopsies and c. Inflammatory bowel disease

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  16. b. Stool examination for ova and parasites-
    should be done especially in those with diarrhea predominant cases in IBS which develop symptoms after acute gastroenteritis. Gastroenteritis is a catchall term for infection or irritation of the digestive tract. Gastroenteritis arises from ingestion of viruses, certain bacteria, or parasites regardless of the cause, the symptoms of gastroenteritis include diarrhea, nausea and vomiting, and abdominal pain and cramps. Sufferers may also experience bloating, low fever, and overall tiredness. Typically, the symptoms last only two to three days, but some viruses may last up to a week.

    b. In This Patient , The Major complains are:low-grade fever and diarrhea with as many as six bowel movements daily, nocturnal diarrhea & abdominal pain before defecating.These are the suspected symptoms for Irritable bowel syndrome.Additional into it,stress is a significant trigger factor in this case who has CHF.

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  18. In this case , patient has abdominal pain or discomfort and accompanied by nocturnal diarrhea and develops abdominal pain before defecating.Relieved with defecation , changes in stool frequency and stool form ( appearance ) are associated features of IBS( Irritable Bowel Syndome).Abdominal pain, bloating, and discomfort are the main symptoms of IBS. However, symptoms can vary from person to person. Some people have constipation, which means hard, difficult-to-pass, or infrequent bowel movements.Some people with IBS experience diarrhea, which is frequent, loose, watery, stools. People with diarrhea frequently feel an urgent and uncontrollable need to have a bowel movement.Abnormal stool form may be lumpy/hard or loose/watery.Abnormal stool frequency may be more than 3 bowel movement per day or fewer than 3 bowel movement per week.Bowel patterns are relatively consistent in most patients, it is not unusual for patients to alternate between constipation and diarrhea.And patient has some other symptoms include noctural symptoms and fever.Leukocytosis is very common in acutely ill patients. It occurs in response to a wide variety of conditions, including viral, bacterial, fungal, or parasitic infection.

    The condition is diagnosed based on its symptoms and by ruling out other diseases. Diagnostic tests may be used to rule out other disorders. These can include stool or blood tests, X-rays, endoscopy and colonoscopy.Since each case is individual, different tests may be reasonable for different patients.biopsies of the duodenum usually will make the diagnosis of celiac disease. Both x-rays and endoscopies can identify anatomic diseases. Only endoscopies, however, can diagnose histological diseases because biopsies (taking samples of tissue) can be taken during the procedure.But we should be aware that not to over investigate. In this case , diarrhoea is predominant symptom than constipation.So checking stool ova and parasites is the most appropriate initiative step after history taking and thorough physical examination.

    b. Stool examination for ova and parasites
    b. Irritable bowel syndrome

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  19. sayarthein , your explain is good .. but what relation between IBS And low grade fever ? think again ..

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  20. This comment has been removed by the author.

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  21. WHY TELLING SO WHILE Inflammatory bowel disease WITH MUCOSAL DESTRUCTION CAN CAUSE LOW GRADE FEVER WIHTOUT MARKED LEUKOCYTOSIS BUT YOUR EXPLANATION IMPEND LEUKOCYTOSIS ..!

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  22. IBS can cause bacterial inbalance in the body, weaking body immune system by overgrowthing of bacteria that can cause fever.
    Small intestinal bacterial overgrowth may tend to cross the mucosal barrier that lining of gut.So immune system respone by increasing of inflammatory cells in the body.This response may get flu like sympoms such as fatigue , pain and low grade fever.

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  23. WHEN THE CONDITION GOES LIKE " Small intestinal bacterial overgrowth may tend to cross the mucosal barrier that lining of gut.So immune system respone by increasing of inflammatory cells in the body " YOU SHOULD DO Upper endoscopy with duodenal aspirates .. YOU CHOOSE
    b. Stool examination for ova and parasites .. WHAT THAT INVESTIGATION LEAD TO ?

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  24. I think it is a case of inflammatory bowel disease because patients with IBD may present with a variety of symptoms. Common symptoms include diarrhea, rectal bleeding, passage of mucus, tenesmus, urgency, and abdominal pain. In more severe cases, fever and weight loss may be prominent.
    Disease of moderate or severe activity often may be associated with systemic symptoms. Patients may develop anorexia and nausea and, in severe attacks, actually may vomit. These symptoms, as well as protein loss through inflamed mucosa, hypercatabolism, and down-regulation of albumin synthesis caused by the inflammation, account for weight loss and hypoalbuminemia that may be profound. Fever, an additional catabolic factor, usually accompanies severe attacks but is typically of a moderate degree.
    In this case the patient has tenesmus, nocturnal diarrhea and diffuse abdominal pain with only systemic symptom of fever.
    Edema caused by hypoalbuminemia may be masked by edema due to CCF.
    In UC digital rectal examination also is frequently normal, but the rectal mucosa may feel “velvety” and edematous. Though here no rectal abnormality is detected, this is not unusual of IBD.

    So far as the laboratory investigation is concerned, laboratory findings in UC are nonspecific and reflect the severity of the underlying disease. Patients with active proctitis and proctosigmoiditis often have normal laboratory test results. Patients with limited distal disease often pass visible blood in the stool, but the amount of blood loss typically is small and anemia, if present, is mild. Here the patient has not yet developed anemia and has mild leucocytosis, which signifies the disease of low grade. Though gross rectal bleeding is not present, occult blood test of stool may be of help.

    The onset of UC typically is slow and insidious. Symptoms have usually been present for weeks or months by the time the patient seeks medical attention. The median interval between the onset of symptoms and diagnosis of UC is approximately 9 months. Some patients with UC may present much more acutely, with symptoms mimicking infectious colitis, which seems to be the case here.

    The peak age of onset of UC and CD is between 15 and 30 years. A second peak occurs between the ages of 60 and 80.
    On the other hand, IBS and diverticulitis are predominantly found in younger population.
    The mean age at presentation of the diverticulitis is 59 years. Although the prevalence among females and males is similar, males tend to present at a younger age.
    Though the recent population-based studies indicate IBS increases with advancing age, it is often misdiagnosed as more and more organic factors like diverticular diseases (which presents with leucocytosis with increased immature polymorphs) and inflammatory bowel diseases are associated with increasing age.
    IBS does not show fever usually if not associated with either an infectious cause or inflammatory cause.

    So considering the age, clinical presentation (though partial) and lab data I think it is a case of inflammatory bowel disease. Further flexible sigmoidoscopy with biopsies and radiological investigations are necessary to confirm the disease

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  25. uuhhh to much comments, and I see a debate between Ibrahim Al-Mahdi(which is case submitter) and Sayarthein(which is in top user list_, gr8.. :).

    Correct Answer are:
    e. Flexible sigmoidoscopy with biopsies
    c. Inflammatory bowel disease


    Winners:
    Kodokter(first correct answer)
    Indrajit(best explain answer)(Indrajit posted answer just some minutes before I publish winners), and second winner was Keila carolina she answer correct with some useful words.

    Good luck next case.


    This case is explained below
    -Patients who have diarrhea associated with fever, abdominal pain, and leukocytosis should be evaluated for the presence of an invasive or inflammatory bowel disease.
    -Visualization and biopsies of the colonic mucosa at the time of flexible sigmoidoscopy or colonoscopy are the definitive studies for diagnosing the cause of invasive or inflammatory diarrhea.

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