A 33 year old male camp counselor seeks medical attention from his primary care physician for the third time this year.  His chief complaint is diarrhea – 4-6 times per day – and episodic right lower quadrant pain.  Rarely does he report bloating and escalating pain after a meal.  He has had no rash.  Occasionally, he gets “painful sores” in his mouth.  He has lost 15# over the last 18 months.

1. Describe the 4 broad etiologies of diarrhea and list examples of each.
   
   
2. Generate a differential diagnosis based on the above history.

   3.  What additional historical features might be useful?

   4.  Request a cost-effective evaluation for this patient.

A 67 year old female retired corporate pilot sees her PCP complaining of chest pain.  As part of her pilot’s physical, she has undergone cardiac catheterization within the past 6 months; this was normal effectively excluding a cardiac etiology.  The pain is further described as intermittent, burning, and nonradiating.  Occasionally, there is difficulty swallowing.  She has failed to improve after taking her husband’s Prilosec® “off and on” for a few days. 

1. List GI causes of non-cardiac chest pain.
   
   

2. Recognize warning signs/symptoms of esophageal complaints.
   
   

3. Define Barrett’s esophagus.
   
   

4. How do we treat gastroesophageal reflux disease (GERD)?
   
   

5. Recognize some extra-esophageal signs/symptoms associated with GERD

A 45 year old policeman is dropped of at the emergency department by his partner after fainting while getting out of the patrol car.  In the ED, he is conversant and vital signs are stable.  He gets lightheaded with standing.  Over the past several weeks, he has noted intermittent stools he can only describe as very dark and “awful smelling.”  He also complains of chronic shoulder pain which has been limiting his sleep. 

1. What additional information might be useful?
   
   

2. With this additional information, what is the most likely cause of his disease?
   
   

3. What is the immediate treatment plan?
   
   

4. Differentiate between upper and lower GI bleeding.

A 26 year old medical student complains to his friends of a stomach ache.  The friend, brushing up on his interview skills, manages to determine that the “ache” is located in the lower abdomen and is intermittent.  The pattern of pain is sharp, lasting seconds to hours.  It is relieved by evacuation of gas or stool.  He also notices that before flying, he will often have 3-4 unformed bowel movements.  Otherwise, our medical student tends to fluctuate between days of constipation followed by a day or two of diarrhea.

1. What is the likely diagnosis?
   
   

2. What should our minimal workup be?

A 51 year old professor presents to his internist for a routine checkup.  As part of the visit, the internist proposes screening for colon cancer.  The professor responds “Why?” Once convinced that this seems reasonable, he asks “What are my options?”

1. Understand the rationale for colon cancer screening.
   
   
2. List the different modalities of screening, the strengths and weaknesses of each.

A30 year old female seeks out a family friend (who also happens to be a physician) coaching her son’s little league team.  She recently tried to donate blood but was denied when her transaminases were found to be elevated (3x normal).  Her history is pertinent for spending the early part of her life in Korea as the child of missionaries, a severe motor vehicle collision while a teen from which she completely recovered, and brief intranasal cocaine usage while employed as a runway model. 

1. What needs to be considered on the differential diagnosis?
   
   
2. What further blood work needs to be obtained?
   
   
3. Understand the distinction between a hepatocellular v. cholestatic laboratory pattern and examples of each.