A School Nurse With Anxiety, Diarrhea, Palpitations, and Cough

Jennifer Wachala, DO; Dushyant Singh Dahiya, MD; Farah Wani, MD; Asim Kichloo, MD


April 19, 2022

Editor's Note:
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.


A 54-year-old woman presents to the emergency department (ED) with a 5-day history of worsening diarrhea and weakness. Her past medical history includes well-controlled type 2 diabetes, gastroesophageal reflux disease (GERD), lymphoma, anxiety, and depression.

The patient describes the diarrhea as three or four loose, watery bowel movements per day. She has no abdominal pain, nausea, vomiting, hematemesis, hematochezia, or stool incontinence. She also reports no recent changes in diet or appetite, changes in weight, changes in medication, recent illness, or travel. She has been taking a psyllium fiber supplement (Metamucil) for 5 days without improvement in her symptoms.

In addition, she reports generalized weakness, which started at about the same time as the diarrhea. She is usually able to take her dogs on a 2-mile walk after work. During the past week, however, she has struggled to walk even half a mile. She has not had any recent falls.

She also reports palpitations that last a few seconds, which she attributes to her anxiety. She has an occasional productive cough with clear phlegm, which she attributes to chronic postnasal drip. She reports no fever, chills, night sweats, lightheadedness, dizziness, changes in vision, nasal congestion, rhinorrhea, sore throat, chest discomfort, shortness of breath, tremors, or urinary symptoms.

The patient works as a nurse in an elementary school. She reports sick contacts, without significant exposure. However, about a week ago, three students and one staff member tested positive for SARS-CoV-2 at the school. The patient underwent a COVID-19 rapid antigen test immediately after the students and staff member tested positive, and her result was negative. She was vaccinated with two doses of the COVID-19 vaccine in 2021 but has not yet received her booster dose.

She lives in a private home with her husband and two dogs. She does not use tobacco products or illicit drugs. She drinks alcohol on occasion.

She reports no recent hospitalizations. Her surgical history is positive for an appendectomy and an open reduction and internal fixation of the right ankle after a traumatic fracture. She has no significant family history. She is highly adherent to metformin therapy, and her A1c level was 5.8% about 4 months ago. Her childhood lymphoma has been in remission for the past 40 years. She takes omeprazole for GERD and attends monthly counseling sessions for her anxiety and depression. She follows up with her primary care provider every 6 months and is up to date on all routine health screening tests for her age, including colonoscopy at age 50 years, which was normal.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.