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Med Surg Case Study #11

Presenting Complaint: Sarah, a 30-year-old female, presents to the clinic with complaints of chronic abdominal pain, bloating, and frequent diarrhea. She reports experiencing these symptoms for several months, which seem to worsen after her favorite breakfast meal, Avocado toast and orange juice. Sarah also mentions feeling fatigued and has noticed unintentional weight loss over the past few months despite maintaining a regular diet.


Patient Background: Sarah has a history of irritable bowel syndrome (IBS) diagnosed a few years ago. She reports no other significant medical conditions and takes no medications regularly.


Assessment: Upon physical assessment, Sarah appears fatigued and slightly underweight. There are no visible signs of malnutrition or deficiencies. Abdominal examination reveals mild tenderness in the upper quadrants, but no masses or organomegaly are palpable. Laboratory tests show a low level of certain vitamins and minerals, including iron and vitamin D.


1. Based on Sarah's history and assessment findings, what is the possible diagnosis for his condition?


2. What diagnostics might be used to confirm the diagnosis?


3. What treatments might be needed for Sarah's condition?




See answers below





Med Surg Notebook




Answers

1. What are the possible diagnoses for Sarah's condition?

Celiac Disease, an autoimmune disorder characterized by an adverse reaction to gluten, causing damage to the small intestine and leading to malabsorption of nutrients.


2. What diagnostics might be used to confirm the diagnosis?

Diagnostic tests:

  • Serologic tests for celiac-specific antibodies: Anti-tissue transglutaminase (anti-tTG), anti-endomysial antibodies (EMA), and anti-deamidated gliadin peptide (anti-DGP) tests.

  • Small intestine biopsy to assess for villous atrophy and inflammation.

  • Genetic testing for HLA-DQ2 and HLA-DQ8 genes associated with celiac disease susceptibility.

3. What treatments might be needed for Sarah's condition?

Possible treatments may include Strict adherence to a gluten-free diet, eliminating all sources of gluten from her diet, including wheat, barley, and rye. Nutritional supplementation to address deficiencies, such as iron, vitamin D, and other vitamins and minerals affected by malabsorption. Referral to a registered dietitian for guidance on a well-balanced gluten-free diet and lifestyle modifications.





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