Case 1
Name
Institution
Course
Instructor
Date
Case 1
Subjective Data
I would inquire about the onset of the loose bowel movement and establish whether it was sudden or insidious. I would also ask about the estimated volume of stool passed per bowel movement, the color of the stool, and whether or not the stool is foul-smelling. Of importance would also be to ask about the factors that relieved the watery bowel movement, the factors that worsen it, and other symptoms that could have been associated with the presenting complaint. Such symptoms include vomiting, nausea, tenesmus, and abdominal pain. It would be of great significance to ask about any history of recent travel, especially to a developing country. I would also find out the kind of food she had ingested 24 hours prior to the onset of the symptoms and if she had taken any untreated water before the onset of the symptoms. Besides the food history, I would try and figure out if there is anyone she was in contact with who presented with similar symptoms. In addition to this, I would ask about any history of recent hospitalization and any history of drug use, especially antibiotics, NSAIDs, and corticosteroids. I would find out from the patient if she has any known gastric or endocrine conditions and inquire about her HIV status. Being a female of reproductive age, I would like to know about her last normal monthly period. I would also like to review respiratory, cardiovascular, gastrointestinal, genitourinary, and musculoskeletal symptoms.
Objective Data
I would like to obtain the patient’s oxygen saturation and obtain the blood pressure when the patient is lying supine. I would also like to assess pallor, jaundice, dehydration, and lymphadenopathy. On the abdominal exam, I would like to inspect the shape and movement of the abdomen, any visible skin changes or scars, and any visible pulsations or distended veins. I would also like to assess the abdomen for any rigidity or guarding. I would also perform a digital rectal exam to check for any evidence of blood or rectal tenderness and to assess the consistency of the stool. I would also like to assess the urine output to check for dehydration. For the chest examination, I would like to assess for deformities, scars, chest expansion, tracheal position, tactile vocal fremitus, and percussion notes on respiratory examination. I would like to evaluate for precordial hyperactivity, distended neck veins, heaves, thrills, and position of the apex beat. On neurological exam, I will obtain data on the patient's level of consciousness, orientation, concentration, speech, muscle bulk, and power.
Diagnostic Exams
I will order the baseline tests of a full blood count, urea, electrolytes, and creatinine levels. I would also like to test the random blood sugar and perform a pregnancy test. To assess for any inflammatory process, I would order for erythrocyte sedimentation rate, and C-reactive protein (CRP) tests. I would order for the stool to be tested for occult blood, leukocyte and lactoferrin levels, and ova and parasites. I would also order for endoscopy to help determine non-infectious causes of diarrhea.
Differential Diagnosis
Infectious gastroenteritis. This can be supported by the symptoms that the patient presented with: watery diarrhea, fever, and flatulence (Onozuka, 2019). The presentation favors a viral cause with the rotavirus being the most probable cause of the infection as it is the most common cause of acute secretory diarrhea in adults.
Inflammatory Bowel Disease. The likelihood of this condition being the diagnosis can be favored by the clinical presentation of acute diarrhea with associated fever and lower abdominal pain in an otherwise normal patient. The patient being of European origin could also make this diagnosis likely (Kaplan, 2021).
Overflow diarrhea from constipation. This is a likely diagnosis based on the presentation of acute diarrhea accompanied by a lower quadrant pain and tenderness
References
Kaplan, G. G., & Windsor, J. W. (2021). The four epidemiological stages in the global evolution of inflammatory bowel disease. Nature reviews Gastroenterology & hepatology, 18(1), 56-66.
Onozuka, D., Gasparrini, A., Sera, F., Hashizume, M., & Honda, Y. (2019). Modeling future projections of temperature-related excess morbidity due to infectious gastroenteritis under climate change conditions in Japan. Environmental health perspectives, 127(7), 077006.