What imaging and workup are recommended for a 45-year-old female presenting with a 4-day history of abdominal pain and constipation, with associated symptoms of flatulence, dry skin, small itchy papules, hair loss, and scalp redness, who has been experiencing abnormal stress due to financial insecurities and has been taking ibuprofen (ibuprofen) and drinking tea for symptom relief?

From the Guidelines

For this 45-year-old female with recurrent abdominal pain, constipation, and dermatological symptoms, I recommend a comprehensive workup including complete blood count, comprehensive metabolic panel, thyroid function tests (TSH, free T4), and inflammatory markers (ESR, CRP) as the initial step in management, as suggested by the most recent guidelines 1. Imaging should start with an abdominal ultrasound to assess for gallbladder disease and other abdominal pathology, given its non-invasive nature and ability to provide valuable information on potential causes of her symptoms 1. If symptoms persist, consider abdominal CT scan and colonoscopy to rule out structural causes of constipation, as these tests can help identify conditions that may require specific interventions 1. A dermatology referral is warranted for evaluation of the widespread papular rash and scalp redness, with possible skin biopsy, to determine the underlying cause of her dermatological symptoms. The patient should also increase water intake to at least 2 liters daily and add fiber to her diet while the workup proceeds, as these lifestyle modifications can help alleviate constipation symptoms 1. A food diary may help identify potential dietary triggers, and stress management techniques should be recommended given her reported financial stressors, as stress can exacerbate symptoms of irritable bowel syndrome (IBS) 1. Given the potential for IBS and mental health comorbidity, a multidisciplinary approach to management should be considered, including referral to a gastropsychologist or specialist gastroenterology dietitian if necessary, as outlined in recent recommendations for managing IBS and mental health comorbidity 1. The constellation of symptoms including constipation, dry skin, hair loss, and rash suggests possible hypothyroidism or other systemic conditions like celiac disease, which should be evaluated through specific testing, including celiac disease screening with tissue transglutaminase antibodies and total IgA, as well as a thyroid antibody panel to evaluate for autoimmune thyroiditis 1. Overall, a comprehensive and multidisciplinary approach is necessary to address the patient's complex symptoms and improve her quality of life, as emphasized in the British Society of Gastroenterology guidelines on the management of IBS 1.

From the Research

Patient Presentation

The patient is a 45-year-old female presenting with abdominal pain and constipation that began 4 days ago. She initially experienced constipation and flatulence, followed by a bowel movement that provided temporary relief but caused pain. She has been taking ibuprofen and drinking tea, which have helped alleviate her symptoms. However, she remains constipated and has noticed dry skin with small, itchy papules throughout her body. She also experiences hair loss when washing her hair and endorses redness on her scalp.

Potential Causes and Workup

Considering the patient's symptoms, the following potential causes and workup may be relevant:

• Thyroid dysfunction: The patient's symptoms of constipation, dry skin, and hair loss could be indicative of hypothyroidism 2. Laboratory tests, such as TSH and free T4, may be ordered to evaluate thyroid function.
• Complex patient concept: The patient's multiple symptoms and potential comorbidities may classify her as a complex patient 3, 4. A comprehensive diagnostic approach, considering medical and non-medical aspects, may be necessary to address her care.
• Gastrointestinal symptoms: The patient's abdominal pain and constipation may be related to gastrointestinal issues, such as Barrett's esophagus 5. Further evaluation, including endoscopy or imaging studies, may be necessary to rule out underlying conditions.

Imaging and Diagnostic Tests

The following imaging and diagnostic tests may be considered:

• Thyroid function tests (TSH, free T4, anti-TPO antibodies) to evaluate thyroid function 2
• Complete blood count (CBC) and electrolyte panel to rule out underlying infections or electrolyte imbalances
• Imaging studies (e.g., abdominal X-ray, ultrasound, or CT scan) to evaluate gastrointestinal symptoms and potential underlying conditions
• Endoscopy to evaluate the esophagus and stomach for potential conditions, such as Barrett's esophagus 5
• Skin biopsy to evaluate the small, itchy papules on her skin
• Hair loss evaluation, including potential laboratory tests (e.g., iron levels, thyroid function tests) to determine the underlying cause of her hair loss.