A 36-Year-Old Man Comes to the Office Due to Frequent

question 747

Multiple Choice

A 36-year-old man comes to the office due to frequent "loose stools" for the past 10 months.  The patient describes stools that are large in volume, liquid to semisolid, occurring up to 3-4 times a day, and often foul-smelling.  He also reports excessive flatulence and occasional nausea and abdominal cramping.  The patient says he may have lost some weight because his clothes are much looser than before.  He has no prior medical problems and takes no medications.  Family history is notable for hypertension and coronary artery disease in his father.  The patient immigrated to the United States from Italy with his family when he was 2 years old and has not traveled out of the country since then.  He does not use tobacco or illicit drugs and drinks alcohol occasionally.  The patient works in a family-owned restaurant and has had no sick contacts.  He consumes a balanced diet and notes no specific association of diarrhea to food.  The patient has been in a monogamous relationship with his wife for the past 10 years.  Temperature is 36.6 C (97.9 F) , blood pressure is 130/86 mm Hg, and pulse is 72/min.  Weight is 63.5 kg (140 lb) .  The sclerae are anicteric, and mucous membranes are moist without any lesions.  Cardiopulmonary examination is unremarkable.  The abdomen is soft, nondistended, and nontender, with no organomegaly.  Bowel sounds are increased.  Rectal examination shows no masses or tenderness and an empty rectal vault.  Stool occult blood testing is negative.  Samples for blood count, erythrocyte sedimentation rate, TSH, and serum electrolytes are obtained.
Which of the following additional interventions is most appropriate in management of this patient's diarrhea?

• A)Advise a trial of lactose-free diet
• B)Arrange for gastrointestinal endoscopy
• C)Obtain CT scan of the abdomen and pelvis with oral contrast
• D)Recommend symptomatic treatment with an antimotility agent
• E)Send stool for microscopy, electrolytes, and fat content

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