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Chief Complaint (CC) “I am here today due to frequent and watery bowel movements”

History of Present Illness (HPI)A 37-year-old European American female presents to your practice with “loose stools” for about three days. One event about every three hours

PMHNo contributory

PSHAppendectomy at the age of 14

Drug Hx No meds

AllergiesPenicillin

SubjectiveFever and chills, Lost appetite Flatulence No mucus or blood on stools

PEB/P 188/96; Pulse 89; RR 16; Temp 99.0; Ht 5,6; wt 110; BMI 17.8

Generalwell-developed female in no acute distress, appears slightly fatigued

HEENTAtraumatic, normocephalic, PERRLA, EOMI, arcus senilus bilaterally, conjunctiva and sclera clear, nares patent, nasopharynx clear, edentulous.

NeckSupple

LungsCTA AP&L

CardS1S2 without rub or gallop

Abdpositive bowel sounds (BS) in all four quadrants; no masses; no organomegaly noted; diffuse, mild, bilateral lower quadrant pain noted Mild diffuse tenderness.

GU Non contributory

Extno cyanosis, clubbing or edema

Integumentgood skin turgor noted, moist mucous membranes

NeuroNo obvious deformities, CN grossly intact II-XII

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Sample Answer

 

 

 

 

Summary of the Patient’s Case

A 37-year-old female presents with a 3-day history of frequent, watery bowel movements (one every 3 hours), low-grade fever (99.0°F), chills, loss of appetite, flatulence, and mild, diffuse lower quadrant abdominal pain with mild diffuse tenderness. Her BMI is low (17.8). Physical exam reveals she is slightly fatigued, and her initial BP is elevated (188/96), though this may be stress-related. She has positive bowel sounds in all four quadrants.

Key Questions to Ask

  • Stool Characteristics: Detailed description of stool (color, consistency, odor, presence of blood/mucus).
  • Pain: Characterize the abdominal pain (sharp, dull, constant, intermittent, location).
  • Associated Symptoms: Nausea, vomiting, urgency, tenesmus, weight loss, dizziness, change in urination.
  • Exposures: Travel, food/water so

Full Answer Section

 

 

 

 

  • Menstrual History: Rule out pregnancy.

Key Physical Exam Findings

  • Vitals: Orthostatic blood pressure and pulse are crucial to assess for dehydration.
  • Abdomen: Detailed palpation for tenderness, guarding, rebound. Auscultate bowel sounds. Rectal exam with Hemoccult/FIT.
  • General: Assess hydration status (mucous membranes, skin turgor).

Differential Diagnoses

  1. Acute Viral Gastroenteritis
  2. Acute Bacterial Gastroenteritis / Food Poisoning
  3. Clostridioides difficile (C. diff) Infection
  4. Parasitic Infection
  5. Irritable Bowel Syndrome (IBS) with Diarrhea (IBS-D) Exacerbation
  6. Inflammatory Bowel Disease (IBD)
  7. Lactose Intolerance / Other Food Intolerance
  8. Hyperthyroidism

Recommended Tests

  1. Stool Studies: Culture, C. diff toxin, Ova and Parasites (O&P) x 3, Fecal Calprotectin/Lactoferrin, Fecal Occult Blood Test (FOBT) or Fecal Immunochemical Test (FIT).
  2. Blood Tests: CBC with differential, BMP, CRP/ESR, TSH with reflex T4, Serum Pregnancy Test (Quantitative hCG).
  3. Imaging: Abdominal X-ray (KUB).

Management

  • Immediate: Rehydration (oral or IV), antiemetics, bland diet, pain management.
  • Based on Results: Antibiotics for bacterial infection, specific treatment for C. diff or parasitic infection, referral for IBD if indicated.
  • Patient Education: Hygiene, “red flag” symptoms, dietary progression, follow-up.

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