Viral Gastroenteritis
Age: years old
Gender:
HISTORY:
Presents with a - history of
Symptoms include:
, episodes , ,
, episodes ,
, , ,
, , , clots
, up to °, over
, , , ,
, over ,
Worsening factors:
Alleviating factors: ,
Contributing factors:
no history of: , , , , , ,
no use of: , ,
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Abdomen: , , , , bowel sounds , ,
Anorectal: DRE , prostate , , , anus
Skin: on
Extremities: , , cap refill sec, pulses , ,
ASSESSMENT:
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: , , , ,
- Stools: , , ,
Treatments:
- Encourage oral rehydration
-
- if no fever or bloody diarrhea
- Dietary modifications:
Further care:
- Referral to infectious disease specialist
- Follow-up in
- Return if symptoms worsen or if new symptoms develop such as recurrent vomiting, high fever, or black stools
HISTORY: EXAM: ASSESSMENT: PLAN: