Vomiting and Diarrhea

Age: ‍ years old

Gender: ‍malefemale



HISTORY:

Presents with a ‍-‍day history of vomiting and diarrhea

Vomiting episodes occurred ‍ times ‍per dayoverall

Vomitus contains ‍undigested foodbileblood

Diarrhea described as ‍wateryloose

Bowel movement episodes occurred ‍ times ‍per dayoverall

Occurs most frequently during the ‍day

Worsening factors: ‍none

Alleviating factors: ‍nonedietary modifications, ‍effectiveineffective



Associated symptoms: *Try using right-click for negatives*

‍abdominal pain, ‍diffuse, ‍dull, ‍mild

‍changes in bowel habits

‍bloating

‍dysphagia

‍heartburn

‍dyspepsia

‍loss of appetite

‍weight loss, ‍ ‍lbskg over ‍ ‍weeksmonths, ‍unintentionalintentional

‍fever, up to ‍°, over ‍ ‍hoursdays

‍chills

‍dehydration signs

‍dizziness

‍anxiety



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, ‍anti-acid, ‍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 ‍

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





ASSESSMENT:

‍Viral gastroenteritis ‍likelysuspectedpossible

DDx: viral gastroenteritis, food poisoning, Bacterial gastroenteritis, parasitic infection, food intolerance, medication side effects, appendicitis, inflammatory bowel disease, celiac disease, lactose intolerance, intestinal obstruction, metabolic disorders, toxic ingestion, urinary tract infection, pancreatitis, peptic ulcer disease, COVID-19





PLAN:

Investigations:

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

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

- CT scan of the abdomen

Treatments:

- Encourage oral hydration

- Oral rehydration therapy

- IV fluids

- ‍Antiemetics

- ‍Antibiotics

- Avoid dairy and fatty foods

Further care:

- Follow-up in ‍ ‍daysweeks

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