A 21-Year-Old Woman With Abdominal Pain and Diminished Academic Performance

Heidi Moawad, MD


August 21, 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 21-year-old woman presents with a 3-month history of stomach aches and intermittent loss of appetite. She says she frequently experiences a sense of emptiness, heaviness, or discomfort of her entire abdominal area, with no localization. Each episode lasts for hours and is not accompanied by sharp pain, fever, diarrhea, constipation, or vomiting. She does not want to eat during these episodes.

She has missed many classes this semester (her junior year of college), and her grades are dropping for the first time in her academic life. She explains that she has had a strong academic record, with a good grade-point average until a few months ago. She is a premed student and plans to apply to medical school during her senior year of college.

The patient reports that she has been particularly distressed by classes that require group projects because she is better at studying for examinations and writing essays or reports. She says the thought of working in groups makes her want to hide and cry. She prefers to work alone. Despite her good grades, she feels like she is not as good as her peers and does not want to spend time with them. She believes her classmates judge her. She has managed group assignments mainly by taking on some of the work and electronically sharing it with her class partners. She is requesting a medical exemption from group work.

She is otherwise healthy and does not take any medication. She is not trying to lose or gain weight. She says she is not pregnant and has never been sexually active. She does not smoke, drink alcohol, or use illicit drugs. When asked about her family history, she replies that her parents do not have any medical problems nor is there a family history of mental illness.

The patient remarks that before she started college, her parents had been in legal trouble, worked irregular hours, and relied on her to take care of her younger siblings. She recalls always being concerned about those legal issues and worried about what might happen to her parents because of them. She felt responsible for her sib and their behavior. She attends school 2 hours away from her family's home and has earned a scholarship that covers college expenses; thus, her educational costs have not been a significant concern for her. She would like to go to a medical school with virtual classes so that she can live with her family because one of her siblings has been in trouble at school recently, which is causing increasing stress for her parents.


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.