BCM Gastroenterology Grand Rounds - History

Identifiers and Chief Complaint:

50 year old woman presents with abdominal pain and weight loss

History of the Present Illness:

She began having diffuse cramping abdominal pain 3-4 months ago. It was worse with meals but there were no other exacerbating or relieving factors. She had occasional nausea but no vomiting. She gradually developed early satiety, subjective fever and night sweats. She had increased abdominal girth and a 40-50 pound weight loss in past 2-3 months. For 3 days she has had small volume, watery, yellowish diarrhea without any blood or mucous. For 2 days the abdominal pain has been severe.

She was admitted to another hospital and noted to have a Hgb of 5.5, which was felt to be secondary to menorrhagia. She was discharged home with iron sulfate after a blood transfusion with plans for a possible hysterectomy.

Previous Medical Diagnoses, Hospitalizations, and Operations:

Gravida 2 Para 2 (both via C-section, last being 22 years ago)

Denies any history of liver disease or malignancy

Medications:

Ferrous sulfate

Ibuprofen prn

Personal and Social History:

Immigrant from Ecuador living in U.S. for past 10 years. Married with 2 adult children.

Occasional alcohol use. No tobacco or substance abuse.

Family History:

No relevant family history of serious diseases