Step by Step Clinical Diagnosis

Document Type : Research Paper

Authors

1 - Professor of Internal Disease, Mashhad University of Medical Sciences, Mashhad,

2 Assistant professor of gastrointestinal disease, Mashhad University of Medical Sciences, Mashhad,

3 Assistant Professor of psychiatry, Mashhad University of Medical Sciences, Mashhad,

4 Fellowship in gastrointestinal disease, Mashhad University of Medical Sciences, Mashhad,

Abstract

A 46 years old gentleman was admitted to hospital following a 10 months history of sever diarrhea. On examination, the patient appeared as mildly dehydrated though his vital sings were within normal limits.important result tests were:
 





Bun=55 mg/dl       Na=149 mEq/dl          WBC=11.6*103/ml           Hemoglobin=16.2 g/d    




Cr=3 mg/dl                K=3.9 mEq/dl     HCT=49.7%     Plt=324*103 Tbo/ul      Neutr=74%      





 
 
 
 
After ten days administration of IV fluid, BUN and createnine gradually became normal (Cr=1.1 mg/dl, BUN=14mg/dl).
There was no macroscopic or microscopic gastrointestinal pathology in upper and lower endoscopy. We took biopsies even from ileum terminal.  
We suspected endocrine tumors and pancreatic disorders, so we requested abdominal and pelvic CT scan (IV and oral contrast) and hormonal tests such as serum cortisole, metanephrin, normetanephrine, which were all normal. We therefore did an octrotide scan which was again normal.
Because almost all organic etiologies of chronic diarrhea were excluded, we focused on neurological and psychological causes of chronic diarrhea. Therefore we consulted with neurologist & psychiatrist and they recommended brain CT scan and EEG which were normal. After complete interview, the psychiatrist diagnosed PTSD and depressive disorder NOS and prescribed imipramin 25mg/day. After 10 days the chronic diarrhea improved. 
As we excluded all the organic causes, we concluded likely the patient had IBS with PTSD and depressive disorder NOS.
 

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medical journal of mashhad university of medical sciences
Volume 55, Issue 3 - Serial Number 3
March and April 2012
Pages 183-189

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