A 39-Year-Old Man With Diarrhea, Weight Loss, and Mood Shifts

Heidi Moawad, MD


May 22, 2023

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 39-year-old man who has had diarrhea for the past 2 months presents for an evaluation. He reports that he has loose stools several times a week. Sometimes the episodes occur daily or up to a few times a day, without any distinguishing pattern of timing. In addition, he has an "upset stomach" from time to time and has vomited five times during the past month.

The patient recently started following a fitness program that involves virtual exercise instruction and a dietary plan that includes beans, fiber-rich grains, and yogurt, all of which he rarely consumed in the past. He explains that the goal of his new diet-and-exercise regimen is to enhance his physical and cognitive capabilities so that he can reach the potential that he was intended to achieve in his life. He says that he has felt energetic over the past few months and has been motivated to make lifestyle changes. He also wants to start his own business.

The patient reports that he had been obese since his teenage years and that he decided to lose weight for health reasons. Three years ago he lost over 80 lb (36.3 kg) by exercising; avoiding deep-fried foods, junk food, and desserts; and eating more nuts and fresh, uncooked vegetables.

He has no history of medical problems, but both of his parents have type 2 diabetes , which was the motivation behind his own weight loss. Before he decided to lose weight, he says that he slept almost all day, every day for nearly a month after he had been laid off from his job. He was concerned that his excessive sleeping could have been indicative of diabetes or another serious medical condition; however, his diagnostic tests were all negative. According to his chart, he received a diagnosis of depression at that time, which he describes as "silly," and he declined treatment.

The patient says that he is highly successful in business and has always done well academically and at work. When questioned about his mood and sleep, he replies that he has been very productive for the past few months and does not require as much sleep as he used to. He is currently sleeping about 4 hours each night and feels well rested and energetic.

The patient's sister, who has accompanied him, reports that he has always been very "picky" and that his mood fluctuates. Upon further questioning, she says that he sometimes seems grumpy and critical of himself and others, whereas at other times he is extremely enthusiastic and full of extravagant plans and ideas. Over the past 15 years, he has left several jobs owing to interpersonal difficulties, and he joined his sister's company 3 years ago. She says that he often thinks he is causing her company to fail, despite her confirmation that the business is financially healthy.

On psychiatric history and mental status examination, his speech was described as "pushy," rapid, and slightly demanding. His affect was optimistic and positive. His thoughts were connected, and there were no hallucinations or delusions. He exhibited obsessions concerning exercise and his stomach. He had no thoughts or plans of suicide nor homicide. He was oriented to time, place, and person. His memory concerning immediate, recent, and distant events was good. Serial sevens findings and interpretation of proverbs showed no abnormalities.


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