Presenting Complaints

The patient, a 39-year-old male, presents with a chief complaint of persistent bloating and abdominal discomfort for the past 3 months.

History of Presenting Complaint

The patient reports that he has been experiencing a feeling of fullness and distension in his abdomen, particularly after meals. He describes the bloating as uncomfortable and sometimes painful, with a sensation of gas buildup. The bloating is often accompanied by mild abdominal cramps and changes in his bowel habits, with alternating episodes of constipation and diarrhea. The patient notes that the symptoms tend to be worse in the evenings and after consuming certain foods, such as dairy products, fried or fatty foods, and foods high in fiber.

Significant Positives & Negatives For Differentials

Irritable Bowel Syndrome (IBS)

Positives:

• Chronic, intermittent nature of bloating and abdominal discomfort
• Association with certain foods (dairy, fried/fatty foods, high-fiber foods)
• Alternating bowel habits (constipation and diarrhea)
• Absence of unintentional weight loss, fever, or blood in stool

Negatives:

• No history of gastrointestinal disorders or chronic medical conditions
• Symptoms may not be severe enough to significantly impact daily life

Small Intestinal Bacterial Overgrowth (SIBO)

Positives:

• Chronic, intermittent bloating and abdominal discomfort
• Association with certain foods
• Alternating bowel habits
• Absence of unintentional weight loss, fever, or blood in stool

Negatives:

• No history of gastrointestinal surgeries or conditions predisposing to SIBO
• Symptoms may not be severe enough to warrant SIBO as the primary diagnosis

Past Medical History

The patient has no significant past medical history. He denies any history of gastrointestinal disorders, abdominal surgeries, or chronic medical conditions.

Drug/Medication History

The patient is not taking any prescription medications. He occasionally takes over-the-counter antacids or gas relief medications when the bloating and discomfort become particularly bothersome.

Social History

The patient is married and works as an office manager. He reports a sedentary lifestyle, with limited physical activity. He denies any history of alcohol or tobacco use.

Family History

The patient's family history is unremarkable, with no known gastrointestinal disorders or other relevant medical conditions.

Systems Review

The patient denies any unintentional weight loss, fever, or blood in his stool. He reports no other significant symptoms in other body systems.

Ideas, Concerns & Expectations

The patient is concerned that the persistent bloating and changes in bowel habits may be indicative of a more serious underlying condition. He is hoping the doctor can provide a diagnosis and effective treatment to alleviate his symptoms.

Case Presentation

Based on the patient's history and presentation, the initial diagnosis the student should arrive at is likely irritable bowel syndrome (IBS) or small intestinal bacterial overgrowth (SIBO). The key features that support this diagnosis include the chronic, intermittent nature of the bloating and abdominal discomfort, the association with certain foods, and the alternating bowel habits.

The student should also consider the following differential diagnoses and be able to explain how they can be ruled out or differentiated based on the patient's history and presentation:

• Celiac disease: The patient does not report any history of gluten intolerance or malabsorption symptoms.
• Lactose intolerance: The patient's symptoms are not exclusively triggered by dairy products.
• Inflammatory bowel disease (IBD): The patient denies any unintentional weight loss, fever, or blood in the stool, which are more common in IBD.
• Intestinal obstruction or malignancy: The patient's symptoms are chronic and intermittent, rather than progressive or severe.

The student should demonstrate their clinical reasoning skills by outlining the next steps in the patient's evaluation, which may include dietary modifications, a trial of probiotics or antibiotics (for SIBO), and potentially further diagnostic testing, such as blood work, stool analysis, or imaging studies, to rule out other underlying conditions.