Needle in a Haystack

A CLINICAL PROBLEM-SOLVING article by Roger Kapoor from Stanford University School of Medicine, California.
A 50-year-old woman reported multiple loose bowel movements associated with mild, cramping abdominal pain. 2 months earlier, her bowel habits changed from one formed stool per day to frequent loose stools of moderate volume. The abdominal pain was variable in intensity and was slightly relieved with defecation.
The patient received a diagnosis of the irritable bowel syndrome, and diphenoxylate–atropine and belladonna–phenobarbital were prescribed. She noted some improvement with this regimen, but she reported tenesmus, and her diarrhea became watery.
Her diarrhea persisted, and occasional nausea, vomiting, fever, and chills had developed.
Six months later, she reported that she was awakened during the night several times each week by fecal incontinence or the need to defecate.
Repeat measurements of potassium showed hypokalemia. Ten months after her initial presentation, the patient had lost a total of 27 lb.
In clinical problem-solving, physicians must continue to evaluate old and new data in order to vigorously evaluate the likelihood of the leading diagnosis. The discussant recognized that in this patient the hypokalemia, nocturnal diarrhea, weight loss, and persistence of watery diarrhea despite medical management were inconsistent with a diagnosis of the irritable bowel syndrome. The patient's partial response to symptomatic treatment appeared to provide the clinicians caring for her with false reassurance and created a sense of premature closure.

瑠璃も針も照らせば光るって諺があります。しつこく光を当て続ければの話で、早期閉鎖してしまうと、診断は闇の中になってしまいます。以前紹介したPDCA(Presenter-Discussant-Commentator-Answer)形式での要約。

P: A 50-year-old woman reported multiple loose bowel movements associated with mild, cramping abdominal pain.
D: Diarrhea is a common symptom with many possible causes.
C: Earlier recognition of secretory diarrhea in our patient would have focused attention on a narrower list of potential causes, allowing the needle — in this case, VIPoma — to be found in the haystack of possibilities.
A: VIPoma