Question

A 68-year-old woman presents with a 4-hour history of severe left-sided abdominal pain. The pain was initially associated with several episodes of diarrhea with some hematochezia. Since then, she has had a few more stools, but she has not seen any more frank blood. Her pain is somewhat improved from what it was at the onset. Past medical history is positive for renal lithiasis and atrial fibrillation. Current medications are digoxin and aspirin. She is a recovering alcoholic who last had a drink 15 years prior to presentation. She recently returned home from a trip to Mexico; she was visiting relatives for 2 months. On exam, you see a well-nourished woman in extreme discomfort. Auscultation of her lungs reveals good breath sounds bilaterally; her heart has an irregularly irregular rhythm with a rate of 92 beats per minute; there is a soft II/VI systolic murmur. Her abdomen is mildly obese and tender on the left side; there is no appreciable mass or rebound. There is no flank tenderness. Rectal exam reveals guaiac positive mucus mixed with flecks of bright red blood. 12 hours after presentation, her left upper quadrant pain is still present; however, it is much improved, and she had only 2 more stools with small flecks of blood in them.

What is the most likely diagnosis?

1 Left ureteral lithiasis
2 Diverticulitis
3 Infectious colitis
4 Small bowel ischemia
5 Ischemic colitis

Answer 1

The most likely diagnosis for the symptoms described is diverticulitis, characterized by acute abdominal pain, changes in bowel habits, and the presence of blood in stools, which matches the symptoms and clinical presentation of the patient.

Step-by-step explanation:

The most likely diagnosis for a 68-year-old woman with a history of severe left-sided abdominal pain, diarrhea, hematochezia, a heart with an irregularly irregular rhythm, and guaiac positive mucus mixed with flecks of bright red blood on rectal exam is diverticulitis. The absence of fever and the localization of pain on the left side, along with tenderness and the history of hematochezia (bright red blood in stools), are typical of diverticulitis.

Diverticulitis often presents with acute, localized, and severe pain, which can be associated with changes in bowel habits such as diarrhea. The patient's recent travel could suggest infectious colitis, but given the patient's age, a history of atrial fibrillation which may complicate as ischemic colitis, and the absence of systemic signs of infection such as fever, diverticulitis is more likely. Her history does not strongly suggest ureteral lithiasis or small bowel ischemia, given the lack of symptoms typical to those conditions such as flank pain or signs of systemic vascular disease, respectively.