Gastroenteritis

HISTORY:

‍Symptoms of gastroenteritis for ‍ ‍hoursdays

‍nausea

‍vomiting, ‍ episodes ‍per day, ‍

‍hematemesis

‍diarrhea, ‍ episodes ‍per day, ‍

‍abdominal pain, ‍diffuse, ‍dull, ‍mild

‍abdominal cramps

‍bloating

‍hematochezia, ‍bright reddark red, ‍around stoolsmixed with stools, ‍withwithout clots

‍mucus in stool

‍tenesmus

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍malaise

‍headache, ‍diffuse, ‍persistentintermittent, ‍pressurethrobbing, ‍mild

‍muscle aches

‍dizziness

‍dehydration signs

‍weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths, ‍unintentionalintentional

Worsening factors: ‍none

Treatments tried: ‍nonedietary modifications, ‍effectiveineffective



EXAM:

General appearance: ‍well-appearing

Vital signs: ‍normal, BP ‍, HR ‍, RR ‍, SpO2 ‍ %, Temp ‍°

Neck: ‍normallymphadenopathy

Heart: ‍RRR, ‍normal S1 and S2

Lungs: ‍clearabnormal sounds, ‍retractions

Abdomen: ‍softsemi-softtense, ‍non-tender ‍, ‍non-distended, ‍

Skin: ‍no rash

Extremities: ‍edema, ‍warm, cap refill ‍< 3 sec> 3 sec, pulses ‍normal, ‍



ASSESSMENT:

‍Gastroenteritis ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍electrolytes, ‍creatinine, ‍LFTs, ‍lipase

- Stools: ‍bacterial culture, ‍parasitic culture, ‍C. difficile toxin, ‍Rotavirus

- Encourage oral rehydration

- ‍Anti-emetics

- ‍Loperamide if no fever or bloody diarrhea

- Dietary modifications: ‍avoid dairy products

- Referral to infectious disease specialist

- Follow-up in ‍ ‍daysweeksmonths

- Return if symptoms worsen or if new symptoms develop such as recurrent vomiting, high fever, or black stools