Gastroenteritis

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of ‍symptoms suggestive of gastroenteritis

Symptoms include:

‍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

Alleviating factors: ‍nonedietary modifications, ‍effectiveineffective



Contributing factors:

‍sick contact with symptoms

‍recent travel

‍recent hospitalization

‍untreated water drinking

‍suspected food poisoning

‍undercooked meat

no history of: ‍irritable bowel syndrome, ‍Crohn's disease, ‍ulcerative colitis, ‍celiac disease, ‍food intolerances, ‍C. difficile infection, ‍cholecystectomy

no use of: ‍antibiotics, ‍laxatives, ‍new medication





EXAM:

General appearance: ‍well-appearing, ‍apparent distress

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

Neck: ‍normal, ‍lymphadenopathy, ‍, c-spine ‍

Heart: ‍RRR, ‍MRG, ‍normal S1 and S2

Lungs: ‍clear bilaterally, ‍abnormal sounds, ‍retractions

Abdomen: ‍soft, ‍non-tender ‍, ‍non-distended, ‍guarding, bowel sounds ‍normal, ‍, ‍CVA tenderness ‍

Anorectal: DRE ‍normal, prostate ‍normal, ‍blood, ‍mass, anus ‍

Skin: ‍rashlesions on ‍

Extremities: ‍warm, ‍dry, cap refill ‍< 3> 3 sec, pulses ‍intact, ‍edema ‍bilaterally, ‍





ASSESSMENT:

‍Gastroenteritis ‍likelysuspectedpossible

DDx: viral gastroenteritis, bacterial gastroenteritis, parasitic infection, traveler's diarrhea, food poisoning, toxic ingestion, medication side effects, inflammatory bowel disease, irritable bowel syndrome, celiac disease, food intolerance, lactose intolerance, ischemic colitis, radiation enteritis, small intestinal bacterial overgrowth, appendicitis, diverticulitis, pancreatitis, peptic ulcer disease, small bowel obstruction





PLAN:

Investigations:

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

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

Treatments:

- Encourage oral rehydration

- ‍Anti-emetics

- ‍Loperamide if no fever or bloody diarrhea

- Dietary modifications: ‍avoid dairy products

Further care:

- 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