A 36-Year-Old Woman With Flatulence and Memory Problems

Alexander Potashinsky, MD; John W. Birk, MD


April 19, 2022

Physical Examination and Workup 

Upon physical examination, the patient is a healthy-appearing woman who is mildly anxious but is otherwise in no acute distress. Her blood pressure is 128/74 mm Hg, with a heart rate of 78 beats/min. Her respiratory rate is 12 breaths/min, with saturation of 99% on room air. She is afebrile, with a temperature of 98.4°F (36.9°C). Her body weight is 188 lb (85.3 kg), and her height is 5' 6" (1.7 m); her resulting body mass index is 30 kg/m2.

The patient's eyes show no scleral icterus, with pupils equally reactive to light and intact extraocular muscle movements. The mucous membranes are moist, with no neck or supraclavicular adenopathy. Auscultation of the lungs reveals normal work of breathing, with clear, symmetrical breath sounds. Cardiovascular auscultation reveals a regular rate and rhythm, with normal heart sounds and absence of murmurs. Abdominal examination reveals an obese, soft, nondistended abdomen, with no tenderness to palpation and normal bowel sounds. Musculoskeletal examination reveals normal joint range of motion, with no swelling or tenderness. Skin examination reveals warm skin and no jaundice. Rectal examination shows normal sphincter tone and soft, brown stool, which is negative for occult blood.

Laboratory testing reveals a normal complete blood count, liver panel findings, and metabolic profile. Serology testing reveals normal thyroid-stimulating hormone (TSH) levels, A1c levels, and serum immunoglobulin (Ig)A tissue transglutaminase levels. Upper esophagogastroduodenoscopy (EGD) reveals a normal esophagus, stomach, and duodenum (Figure 1).

Figure 1.

Six random biopsy samples are obtained from the duodenal bulb and distal duodenum. Pathologic examination reveals normal duodenal histology, except for mildly increased intraepithelial lymphocytes. No crypt hyperplasia or villous atrophy is present (Figure 2).

Figure 2.


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