A 35-year-old female presents to the emergency department with a 3-day history of severe, cramping abdominal pain localized to the right lower quadrant, accompanied by persistent non-bloody diarrhea, occurring 6-8 times per day. She reports intermittent episodes of similar but milder symptoms over the past three years, for which she was empirically treated with antidiarrheals with only partial relief. Over the last 6 months, she has noticed a 7 kg unintentional weight loss and occasional migratory joint pains. She denies fever but reports feeling generally unwell and fatigued. Her past medical history is significant for an incomplete workup for chronic diarrhea a year ago, which included a colonoscopy with findings suggestive of chronic inflammatory changes in the terminal ileum, though a definitive diagnosis was not established. She is currently taking no regular medications. On physical examination, she appears pale and thin, with moderate tenderness to palpation in the right lower quadrant, without rebound or guarding. Bowel sounds are hyperactive. There is no evidence of perianal disease. Her vital signs are: blood pressure 105/60 mmHg, heart rate 98/min, respiratory rate 18/min, temperature 37.8 C. Her body mass index is 19 Kg/m2. What is the most likely diagnosis, and what would be the immediate next step in her management?

A 35-year-old woman with a long-standing history of Crohn's disease, involving extensive small bowel disease requiring an ileal resection 5 years ago, presents for a routine follow-up at the gastroenterology outpatient clinic. She reports persistent mild fatigue and occasional muscle aches, but denies acute abdominal pain or significant changes in bowel habits. She has been diligent with her mesalamine therapy. Her last bone density scan 2 years ago showed osteopenia. She is concerned about long-term complications of her condition. Her vital signs are: Temperature 37.0°C, blood pressure 118/75 mmHg, pulse rate 78/min, respirations 16/min, and oxygen saturation 98% on room air. Physical examination reveals a thin woman, not in acute distress. Her abdomen is soft, non-tender, with no palpable masses. Mild pallor is noted, but no peripheral edema or rashes. Given her clinical history and current concerns, what is the most appropriate initial management strategy for this patient, and what metabolic complication should be continuously monitored?

A 32-year-old man presents to the Emergency Department complaining of severe abdominal pain, frequent watery stools, and persistent fatigue. For the past 8 months, he has experienced intermittent episodes of abdominal cramping and non-bloody diarrhea, which have recently worsened significantly. He reports several episodes of low-grade fever over the last month, a 10 kg unintentional weight loss, and recurring oral aphthous ulcers. His medical history includes recurrent kidney stones. He denies any recent travel or use of new medications. On examination, his temperature is 38.3°C (100.9°F), blood pressure is 105/65 mmHg, pulse is 92/min, and respirations are 16/min. He appears visibly fatigued. Abdominal examination reveals diffuse tenderness, particularly in the right lower quadrant, with mild rebound tenderness. Perianal skin tags are noted. Given his presentation, what are the most appropriate initial diagnostic steps to confirm the diagnosis and guide immediate therapeutic management?

A 13-year-old girl is brought to the outpatient gastroenterology clinic by her parents due to a persistent and worsening constellation of symptoms. For the past year, she has experienced recurrent episodes of diffuse abdominal pain, often accompanied by non-bloody diarrhea followed by occasional streaks of blood in her stool. These episodes last several days and are becoming more frequent, significantly impacting her school attendance and participation in extracurricular activities. Her parents also note a subtle but progressive decline in her energy levels and a concerning weight loss of 5 kg over the last six months, despite a seemingly adequate caloric intake. She denies any recent travel or specific dietary changes. Her current medications include a multivitamin she started on her own. On physical examination, her temperature is 37.10C, blood pressure is 108/65 mmHg, pulse is 92/min, and respirations are 14/min. She appears pale and somewhat lethargic, with notable conjunctival pallor. Her growth chart indicates she has fallen from the 50th to the 25th percentile for weight. Abdominal palpation reveals mild tenderness in the right lower quadrant without rebound or guarding. Dermatological examination identifies a few tender, erythematous nodules on her bilateral shins. Given her symptoms, an abdominal computed tomography (CT) scan was performed, revealing diffuse thickening and luminal narrowing of the terminal ileum with adjacent fat stranding. Which initial diagnostic evaluation and subsequent management approach is most appropriate for this patient?

A 30-year-old male presents to an outpatient gastroenterology clinic complaining of a 6-month history of intermittent abdominal discomfort, predominantly localized to the right lower quadrant, accompanied by chronic, non-bloody diarrhea. He reports having 5-7 loose bowel movements daily, often immediately after meals, which has led to a significant impact on his daily activities. Despite dietary modifications, his symptoms persist, and he notes persistent fatigue and a 7 kg weight loss over the past four months. He denies recent foreign travel or use of new medications. On physical examination, he appears thin with a BMI of 19. Abdominal palpation reveals mild tenderness in the right lower quadrant, but no rebound or guarding. Perianal inspection reveals hypertrophic skin tags and a painful anal fissure. Digital rectal exam is deferred due to discomfort. His vital signs are stable. Given these findings, what is the most likely diagnosis, and what initial diagnostic and therapeutic steps should be considered?

A 38-year-old male with a 10-year history of Crohn's disease, generally well-controlled on maintenance therapy, presents to the urgent care clinic complaining of sudden onset of severe left eye pain, intense photophobia, and excessive lacrimation for the past 24 hours. He denies any recent trauma, foreign body sensation, or changes in vision, though he notes the light sensitivity makes it hard to open the eye. His last significant flare of Crohn's disease was 6 months ago, which was managed conservatively. On examination, his visual acuity is 20/25 in the left eye and 20/20 in the right. The left eye exhibits marked circumcorneal injection, but the conjunctiva appears otherwise clear without discharge. Pupillary reaction in the left eye is sluggish, and the pupil is notably miotic compared to the right. There is no proptosis or eyelid swelling. Given his presentation and medical history, what is the most probable ocular diagnosis and the appropriate initial therapeutic step?

A 28-year-old woman presents to her primary care physician with a 3-month history of intermittent, crampy lower abdominal pain and frequent, non-bloody diarrhea. She reports significant fatigue, occasional low-grade fevers, and unintentional weight loss of 4 kg over the past two months. Her symptoms have worsened over the last week, prompting this visit. She mentions developing painful mouth sores periodically, and a tender, red lump on her shin appeared yesterday. She denies recent travel or sick contacts. Her vital signs today are: temperature 37.80C (100.00F), blood pressure 128/78 mmHg, pulse 92/min, respirations 14/min, and oxygen saturation 97% on room air. Physical examination reveals an uncomfortable but cooperative patient. Abdominal palpation elicits tenderness, particularly in the right lower quadrant, with no rebound or guarding. Oral examination shows several shallow aphthous ulcers. A 2 cm erythematous, warm, and tender nodule is noted on her right pretibial area. The remainder of her physical exam is unremarkable. Laboratory results are pending and are shown below. Considering her clinical presentation and the most likely underlying pathology, which of the following describes her condition and the most appropriate initial management for this exacerbation?

A 32-year-old woman presents to a gastroenterology outpatient clinic with a 6-month history of intermittent abdominal pain, persistent non-bloody diarrhea (though recent episodes have had streaks of blood), and significant fatigue. She reports an unintentional weight loss of 7 kg (approximately 15 pounds) over the past 3 months despite a good appetite. She also notes recurring painful aphthous ulcers in her mouth and recent onset of migratory joint pain affecting her knees and ankles. Her past medical history includes iron deficiency anemia diagnosed 2 years prior, for which she intermittently takes iron supplements, and anxiety. Her current medications include an oral contraceptive and occasional loperamide for diarrhea. On examination, her temperature is 37.5°C, blood pressure 105/70 mmHg, pulse 98/min, respirations 16/min, and oxygen saturation 99% on room air. She appears somewhat pale and thin, with mild tenderness to palpation in the right lower quadrant of the abdomen. Bowel sounds are hyperactive. Oral examination reveals a 1 cm shallow ulcer on the buccal mucosa. There is no clubbing or peripheral edema. A stool sample sent for analysis on presentation returned positive for occult blood. Considering her clinical presentation and initial laboratory findings, which of the following represents the most appropriate diagnostic marker and initial therapeutic approach?

A 30-year-old woman presents to her gastroenterologist's clinic for a follow-up visit after experiencing several episodes of acute flank pain and hematuria over the past year, consistent with recurrent nephrolithiasis. Her medical history includes well-controlled Crohn disease, type 1 diabetes mellitus, and chronic gout managed with insulin, sulfasalazine, and allopurinol, respectively. She reports good adherence to her current medication regimen. Her current vital signs are stable: temperature 37.0°C, blood pressure 118/75 mmHg, pulse 78/min, and respirations 16/min. On physical examination, there is mild tenderness in the right lower quadrant, but no costovertebral angle tenderness. She is concerned about the recurrence of her kidney stones. Given these findings, what is the most likely underlying condition contributing to this patient's recurrent nephrolithiasis, and what is the cornerstone of long-term dietary management?

A 25-year-old woman presents to an outpatient gastroenterology clinic complaining of chronic, intermittent lower abdominal pain, often migrating, accompanied by recurrent episodes of bloody diarrhea, fatigue, and unintentional weight loss over the past six months. She also reports occasional oral aphthous ulcers. Her medical history is significant for iron-deficiency anemia, which has required intermittent treatment. Her family history includes a paternal aunt with Crohn's disease and a maternal grandmother with ulcerative colitis. She is a graduate student, a non-smoker, and rarely consumes alcohol. On examination, she appears fatigued. Her temperature is 37.80C (100.00F), blood pressure is 105/65 mmHg, pulse is 98/min, and respirations are 16/min. Abdominal palpation reveals mild tenderness in the right lower quadrant with some guarding, but no rebound. Perianal examination reveals a small, healing perianal fissure. Given these findings, what is the most likely diagnosis and the most appropriate initial diagnostic step to confirm it?

A 32-year-old woman presents to a gastroenterology clinic with a 6-week history of worsening symptoms. She reports persistent crampy abdominal pain, predominantly in the right lower quadrant, accompanied by frequent non-bloody diarrhea, occurring 5-6 times daily, occasionally mixed with mucus. She has experienced an unintentional weight loss of 5 kg over the past two months and describes profound fatigue that impacts her daily activities. She recalls a similar, milder episode about three years ago, which resolved spontaneously and was attributed to "stress-induced colitis." Her elder sister was recently diagnosed with a chronic autoimmune condition affecting the intestines. The patient denies recent travel, antibiotic use, or consumption of raw seafood. On examination, she appears frail and pale. Vital signs include a temperature of 37.8°C, blood pressure 105/70 mmHg, pulse 95/min, and respiratory rate 16/min. Abdominal palpation elicits tenderness in the right iliac fossa with palpable fullness but no rebound tenderness or guarding. Examination of the oral cavity reveals multiple discrete aphthous ulcers on the buccal mucosa. A biopsy taken from one of these oral lesions during a prior visit revealed non-caseating granulomatous inflammation. Given her presentation and findings, what is the most likely diagnosis and the appropriate initial therapeutic approach?

A 32-year-old man presents to the emergency department with a 3-week history of worsening abdominal pain, persistent bloody diarrhea (8-10 episodes daily), and significant fatigue. He reports a 4 kg weight loss over the last month and occasional low-grade fevers. He denies recent travel, antibiotic use, or known sick contacts. His medical history is unremarkable. On physical examination, he appears pale and unwell. Vital signs include a temperature of 38.2°C, heart rate of 98 bpm, blood pressure of 110/70 mmHg, and respiratory rate of 16 breaths/min. Abdominal examination reveals diffuse tenderness, primarily in the right lower quadrant, with mild guarding but no rebound tenderness. Digital rectal examination shows blood-streaked stool. Initial laboratory findings are available. Subsequent colonoscopy revealed discontinuous areas of deep ulceration and inflammation affecting the ascending and transverse colon, with intervening segments of healthy-appearing mucosa. The rectum appeared spared. Biopsies from the affected areas showed transmural inflammation and non-caseating granulomas. Considering his presentation and findings, what is the most likely underlying diagnosis and the immediate therapeutic approach that should be initiated?

A 28-year-old man presents to the general internal medicine clinic complaining of intermittent abdominal pain and chronic non-bloody diarrhea that has persisted for over 8 months, accompanied by unintentional weight loss of 4 kg. He reports a history of perianal skin tags and a recurrent oral ulceration in the past year. He denies any recent travel or use of new medications. On physical examination, he appears thin. Vitals are stable. Abdominal palpation reveals mild diffuse tenderness, most pronounced in the right lower quadrant, without guarding or rebound. Perianal inspection shows an active perianal fistula. Multiple aphthous ulcers are noted on the buccal mucosa. What is the most appropriate initial diagnostic investigation and subsequent therapeutic approach?