Internal Medicine Case Challenge: A Highly Active 80-Year-Old Woman With Sudden Illness

Zafar Jamkhana, MD, MPH; Nirav Patel, MD


April 03, 2023

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The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


An 80-year-old woman presents to the emergency department with symptoms of malaise, nausea and vomiting, abdominal pain, and watery diarrhea. She had been in her usual state of health until the symptoms started about 2 to 3 days ago. The patient's daughter reports that the patient is highly active, with a full-time job as a realtor. She lives alone on a 3-acre farm located in southern Illinois, and does the gardening by herself. The diarrhea is watery without any blood in the stool. She also reported that the patient found a tick on her body about 3 to 4 weeks ago (Figure 1).


The patient has a history of hypertension and hyperlipidemia, and has been receiving oral medications for 15 years. She also has had ulcerative colitis for 30 years and has been controlled with sulfasalazine. The patient is a nonsmoker and does not consume alcohol or drugs.


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