Vomiting and Diarrhea

HISTORY:

Vomiting and diarrhea for ‍ ‍hoursdays

Vomiting episodes: ‍ times ‍per dayoverall, ‍undigested foodbileblood

Diarrhea episodes: ‍ times ‍per dayoverall, ‍wateryloose

Worsening factors: ‍none

Treatments tried: ‍nonedietary modifications, ‍effectiveineffective

‍abdominal pain, ‍diffuse, ‍dull, ‍mild

‍hematemesis

‍hematochezia

‍dark, tarry stools

‍bloating

‍weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths, ‍unintentionalintentional

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍dehydration signs

‍dizziness

‍anxiety



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, ‍

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



ASSESSMENT:

‍Viral gastroenteritis ‍likelysuspectedpossible

DDx: ‍



PLAN:

- Blood work: ‍CBC, ‍lytes, ‍creatinine, ‍glucose, ‍LFTs, ‍CRP

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

- CT scan of the abdomen

- Encourage oral hydration

- Oral rehydration therapy

- IV fluids

- ‍Antiemetics

- ‍Antibiotics

- Avoid dairy and fatty foods

- Follow-up in ‍ ‍daysweeks

- Return if symptoms worsen or if abdominal pain, fever, or blood in stools develop