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HPI:
Pt is a [_] who presents with [< 2 weeks, Persistent 2-4 weeks, chronic >4 weeks] of diarrhea. [_]
[-Fever, Vomiting, bloody
-Travel, exposure to ground water, springs or rivers
-Stools per day, small vs large volume
-Sick contacts, hospitalizations, occupation
-Med Hx: Abx, SSRIs, metformin
-PMH: immunocompromised, cholecystectomy, pancreatic resection, HIV]
REVIEW OF SYSTEMS:
Gen: Denies fevers/chills and weight loss
CARDIAC: No syncope, palpitations, dizziness or orthostatic symptoms
GI: No abdominal pain, melanotic stools, or BRBPR
Vitals: [Stable]
PE:
GEN: In no apparent distress.
Pulmonary: Lungs are clear to auscultation bilaterally.
CV: Heart has a regular rate and rhythm without a murmur.
Back: No CVA tenderness.
Abdomen: Normal bowel sounds. Soft, nondistended. No organomegaly. No rebound or guarding. No masses. Tenderness in the [the abdomen diffusely].
ASSESSMENT/PLAN:
1 Diarrhea
Pt presents with acute diarrhea likely secondary to probable viral etiology (Rotavirus-most common in children, Norovirus-most common in adults, Adenovirus, Astrovirus). Currently without orthostatic symptoms and vitals are stable and appropriate. Pt does not present with reg flag symptoms including: fever, duration >72hr if immunocompetent (or <72h if immunocompromised), bloody stools, and hypovolemia.
[-Will move forward with laboratory assessment as Pt has symptoms of dysentery, moderate or severe watery diarrhea, increases risk of spreading (heath care worker, food industry worker, daycare worker), pronged illness (water and duration >72hr), immunosuppression
– Will consider CBC, CMP, C diff, GI PCR (Salmonella, E coli, Shigella, Yersinia, Campylobacter, Giardia PCR panel). Viral PCR (outbreak in center, cruise ship) EHEC, shigella, entamoeba culture]
-Clear liquids for 24 hours, then slowly advance diet (boiled vegetables, starches, soups, yogurt. Avoid high fat foods). No medications prescribed currently. Pt was advised to use [Online oral rehydration solution, diluted fruit juices, Pedialyte, etc.]
-Initiate treatment with Bismuth (3-4x/day), oral probiotic, simethicone and loperamide (Imodium-for acute watery diarrhea only, avoid in blood or suspected inflammatory diarrhea due to risk of toxic megacolon and prolonged illness)
-Handout provided on viral gastroenteritis.
-Follow-up in ER if symptoms worsen or do not improve within one to two days, fever, or increased pain.
[-As Pt is immunocompromised consider other infectious etiologies including cytomegalovirus, Cryptosporidium, Cystoisospora, Mycobacterium avium complex, microsporidia, and disseminated TB.
-Consider sigmoidoscopy
-Large volume diarrhea is likely a result of pathology located in the small bowel to right colon. Diarrhea with small volume with frequent episodes is likely a result of pathology in the left colon or rectum
As Pt has severe travelers diarrhea, bloody stools with fever, sepsis, or immunocompromised we will plan on empiric abx therapy. (Fluoroquinolone or macrolide]
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