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Comprehensive iHuman Case Study 25-Year-Old Female with Loose Stool - Week #7 Detailed Report & Analysis
Typology: Exams
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a 25 yo male with abrupt onset watery diarrhea with blood and diffuse abdominal pain after recent workrelated travel and eating undercooked meat. Additionally, he reports lightheadedness, a mild headache, minimal nausea, and no vomiting. Physical exam reveals he is febrile 101.5F, pulse 102, dry mucous membranes, decreased skin turgor, orthostatic hypotension, and guaiac-positive stool per rectal exam, but is negative for rebound tenderness, referred pain, antibiotic use, palpable abdominal masses or rectal lesions.
Diagnostic Testing: WBC 13,500, Bands 10% Stool culture +Salmonella enteritidis, Medications/Treatment: gram (-) bacilli; fecal leukocytes >10,000 WBC OTC Loperamide (Imodium) 4mg PO initially, followed by 2mg after each unformed stool. Max 16mg/day Ciprofloxacin 500mg Consults/Referrals: Gastroenterology canceled Supportive Care: PO twice daily x3 days Oral Rehydration - electrolyte replacement drinks, broths Bland diet until appetite and normal bowel habits return Avoid caffeine - coffee, tea, Patient Education: chocolate Return to work once diarrhea has resolved Patient was cautioned on consuming raw/undercooked meats Reminded of the importance of good hand hygiene practices for transmission Follow Up: Symptoms should improve within 24 - 48 hours of starting antibiotics If symptoms worsen, return to the office or go to the ER if severe prevention of Reference: Akhondi, H. & Simonsen, K., (2023, August 7). Bacterial diarrhea. National Library of Medicine. Bacterial Diarrhea - StatPearls - NCBI Bookshelf (nih.gov) Epocrates (n.d.). Diseases: Salmonella infection. Retrieved October 8, 2023, from
https://www.epocrates.com/online/diseases/817/salmonella-infection#highlights-basics Meisenheimer, E., Epstein, C., & Thiel, D., (2022). Acute diarrhea in adults. American Academy of Family Physician, 106(1), 72-80. https://web-s-ebscohost- com.chamberlainuniversity.idm.oclc.org/ehost/pdfviewer/pdfviewer? vid=0&sid=92e1404d-d0e3-4ee1-afb9-21df6e19ebd7%40redis
Category Reason for Encounter c/o diarrhea History of present illness Recent work trip to Chicago. Current symptoms started with anorexia which then turned into diarrhea x3 days. Watery stool every 2 hours, even at night, with "streaks of blood"; Stomach pain at rest rated 7 - 8/10 before diarrhea, 4/10 after passing stool. Recently ate rare beef.
Category Data Past Medical History No recent infections or antibiotic use; no personal history of colon cancer Hospitalizations / Surgeries no recent hospitalizations, surgeries, or procedures
Category Data Medications OTC Kaopectate for diarrhea
Category Data Allergies No stated allergies
Category Data
Preventive health up to date on annual flu vaccine; unable to answer if HBV vaccine is up to date
Category Data Family History No family history of colon cancer No known familial genetic disorders
Category Data Social History Denies smoking or drug use; consumes 3 - 4 glasses of red wine/week, liquor on rare occasion
Category Data General states his stomach feels sore and crampy all over; denies unintentional weight loss or gain; fever with chills, feeling "wiped out", and poor sleeping since onset; fatigue with onset of current symptoms Integumentary / Breast no complaints of bruising or bleeding of the skin HEENT / Neck no complaints of vision or hearing changes, ear pain, sinus problems or sore throat Cardiovascular Denies chest pain, palpitations, changes in exercise tolerance Respiratory Denies ShOB with URI or without exertion; no cough; no recent Gastrointestinal Watery diarrhea every 2 hours streaked with red blood, no incontinence; midstomach soreness and cramping that "comes and goes"; bloating without flatus, mild nausea, regurgitation no vomiting; no heartburn or Genitourinary no changes in urination Musculoskeletal no complaints of muscle or joint pain Allergic / Immunologic no complaints Endocrine changes in appetite associate with diarrhea onset Hematologic / Lymphatic streaks of bright red blood in diarrhea; denies bleeding/bruising concerns Denies tenderness/inflammation of lymph nodes other Neurologic (^) complaint of mild headache, onset with dizziness, fainting, tingling, or numbness diarrhea; no Psychiatric no stated changes in mood
Category Data General cap refill bilateral UE normal; mucus membranes dry Skin skin is warm, slightly diaphoretic; mild to moderate decrease in skin turgor; no rash, lesions, petechiae, icterus, or pallor noted HEENT / Neck Eyes: conjunctivae pink, no discharge, sclerae anicteric Ears: normal appearing pinna, no discharge or deformities Nose: no discharge or polyps; no tenderness on frontal or maxillary sinuses Mouth: dry MMs and tongue; tonsils without exudate Neck: thyroid firm, no nodules palpated, moves with swallowing; full range of motion Cardiovascular heart sounds normal with regular rate and rhythm Chest / Respiratory chest wall symmetrical, AP diameter is normal; Excursion with respiration is symmetrical; no retractions noted; normal breath sounds anterior and posterior Abdomen normal and symmetric, with no deformities or herniation; normoactive bowel sounds; no tympany or shifting dullness on percussion; Liver 12cm at MCL; spleen tip palpable with inspiration; diffuse tenderness to palpation, no guarding; no rebound tenderness, no palpable herniation; no fluid wave Genitourinary / Rectal no visible fissures, induration or rectal lesions; rectal exam revealed no masses guaiac-positive or localized tenderness, but residue Musculoskeletal / Osteopathic Structural Examination no cyanosis, clubbing, or edema noted on extremities Neurologic (^) Alert and oriented x Currently rating pain 4/10 (^) diffusely over abdomen Psychiatric mood appropriate for current condition Lymphatic (^) no enlarged lymph nodes inguinal chains in cervical, supraclavicular, axillary, or