Patient’s Information
Age: 36. Sex: Female.
Subjective
Chief Complaint
“Diarrhea for the last three days.” It increases if the patient eats milk. It decreases with fasting. No mucus or blood. No fever, cough, vomiting, nausea, adnominal pain, and tenesmus.
History of the Present Illness
Diarrheas began three days ago. It increases if the patient eats milk and decreases with fasting. Neither mucus nor blood is observed. No fever, cough, vomiting, nausea, adnominal pain, and tenesmus.
Vaginal discharge has recently been observed. Now, it is not present. The patient is on her 7th day of treatment.
Medications
Gynecologist prescribed Levaquin 500 mg po qd x 10 days to treat her vaginal discharge.
Past Medical History
Allergies
Not detected.
Medication Intolerances
Not detected. Still, diarrhea began with the usage of antibiotics (Levaquin).
Chronic Illnesses/Major traumas
Herpes 2 virus last five years.
Hospitalizations/Surgeries
No information.
Family History
No significant family history.
Social History
No significant social history.
Review of Systems (Only Symptoms)
- General N/A.
- Cardiovascular N/A.
- Skin N/A.
- Respiratory N/A.
- Eye N/A.
- Gastrointestinal N/A.
- Ears N/A.
- Genitourinary/Gynecological: Herpes 2 viruses (last five years).
- Nose/Mouth/Throat N/A.
- Musculoskeletal N/A.
- Breast N/A.
- Neurological N/A.
- Heme/Lymph/Endo N/A.
- Psychiatric N/A.
Objective
Weight: 113 lb. BMI 20.02. Temp N/A. BP 90/60. Height 160 cm. Pulse 80 per minute. Resp 14 per minute.
General Appearance
Healthy appearing adult woman.
Skin
No cyanosis.
HEENT
Moist oral mucosa.
Cardiovascular
Normal pulses.
Respiratory
Lungs are clear.
Gastrointestinal
Abdomen increases peristalsis to auscultation. The abdomen is nontender without masses and hepatosplenomegaly
Breast
N/A.
Genitourinary
Pelvis nontender. No nodes. External genitalia is shaved. Neither edema, nor erythema, nor exudates.
Musculoskeletal
- No edema.
- Neurological: N/A.
- Psychiatric: N/A.
- Lab Tests: N/A.
- Special Tests: N/A.
Diagnosis
Differential Diagnoses
Enterocolitis due to Clostridium difficile
Enterocolitis due to Clostridium difficile (ICD-10-CM: A04.7) is the type of inflammation that can be observed in people of all ages. Clostridium difficile is the bacterium that causes this disease. It can grow in the large intestine for some time. Soon, it releases harmful toxins that cause different problems. The activation of this bacterium is usually associated with prior antibiotic usage (Polage, Solnick, & Cohen, 2012). Therefore, the patient can have this disease because of her recent usage of Levaquin, the type of antibiotics that aim at fighting against bacteria in the organism.
Malabsorption due to intolerance
Malabsorption due to intolerance (ICD-10-CM: K90.4) is the condition when a reduced expression of lactase is observed after the ingestion of dairy products (Misselwitz et al., 2013). Protein intolerance is the reason for many gastrointestinal manifestations without the involvement of other organ systems. This diagnosis can be given to the patient because diarrhea increases each time she eats milk. The problem decreases as soon as the patient stops eating milk and begins fasting. Diarrhea is one of the symptoms of malabsorption of milk and other dairy products.
Dehydration
Dehydration (ICD-10-CM: E86.0) is the condition when a person loses too much water from the organism. Its etiology includes viral gastroenteritis, and the flora of intestines is damaged considerably. Diarrhea may cause dehydration (Barr & Smith, 2014). It is necessary to know that dehydration has a certain impact on the work of other organs, including kidneys and lungs. Thirst and fatigue are the main symptoms of this disease. The patient has some problems with her mouth, and the physician should follow the condition of her skin and the ability to sweat.
Diagnosis
Diarrhea due to antibiotics, ICD-10-CM
Toxic gastroenteritis and colitis is the antibiotic-associated disease that is characterized by loose stool and bowel movements. As a rule, it may begin in one week or even earlier after the patient starts taking an antibiotic. Sometimes, the symptoms can be observed later. In this case, the female patient started taking Levaquin seven days ago. Loss of appetite, nausea, and low fever can be additional symptoms. Still, the patient denies all of them during her physical examination. If diarrhea cannot be stopped, it causes dehydration, and this condition is life-threatening. The condition of a mouth, urination frequency, and general condition (including weakness and fatigue) should be taken into consideration.
Plan/Therapeutics
Plan for Diarrhea Treatment
Further testing
- Stool pH level to identify if there is a bacterium or parasite in the organism.
- A blood test to determine the presence/absence of infection.
- Colonoscopy.
Medication
Stop the usage of all antibiotics.
Education
The patient should be learned about the fact that diarrhea is the disease that can clear on its own in several days without any treatment.
Non-medication treatments
- Lactobacillus acidophilus to take orally three times per week (Sinclair, Xie, Saab, & Dendukuri, 2016).
- Low-fat diet.
Follow-up
Visit a physician in three days to check if malabsorption occurs. Visit a gynecologist to check a vaginal discharge.
Plan for Enterocolitis due to Clostridium difficile Treatment
Further testing
Stool sample to be tested for toxins
Sigmoidoscopy to look at the colon and detect the presence/absence of yellow or white tissue on the colon’s inside
Medication
Stop taking any antibiotics that may cause an infection.
Choose another antibiotic, e.g., Metronidazole 500 mg three times per day for ten days (Surawicz et al., 2013).
Education
The patient should understand that surgery can be the option of treatment when a diseased colon has to be removed.
Non-medication treatments
Probiotics can be used to include bacteria that are crucial for keeping microflora of the intestines.
Follow-up
A gastroenterologist has to be addressed in five days to check the effectiveness of the antibiotics chosen. In the case of negative outcomes observed earlier, an urgent visit is possible.
Plan for Malabsorption due to intolerance Treatment
Further testing
- Lactose tolerance test
- Lactase activity in mucosal biopsies from the duodenum test (Misselwitz et al., 2013).
- Genetic tests to establish lactase non-persistence (Misselwitz et al., 2013).
- Hydrogen breath tests to measure the level of hydrogen (Misselwitz et al., 2013).
Medication
No medications are required.
Education
The patient should know that treatment of this disease does not aim at malabsorption reduction but the improvement of digestive symptoms (Misselwitz et al., 2013).
Non-medication treatments
The patient has to avoid large portions of milk and various dairy products. Lactose-reduced products are required. The serving size of lactose is 12 g (1 cup of milk).
Follow-up
A visit to a gastroenterologist is obligatory in the next five days.
Plan for Dehydration Treatment
Further testing
A blood test to check the level of electrolytes and the work of kidneys
Urinalysis to check the level of the organism’s dehydration and the presence/absence of some bladder infection
Medication
No medications are suggested because of the possibility to use salts as the main treatment
Education
Dehydration is a life-threatening disease. Its risk is the possibility to be developed slowly and has a considerable impact in a short period. Disorientation and weakness are the possible outcomes of dehydration. Heart and kidney problems can be observed. If there are some chronic illnesses, the patient may be at risk.
Non-medication treatments
Rehydration, with the help of ORS (oral rehydration salts), can be offered (Farthing et al., 2013). Drink more water and other fluids to improve the level of hydrogen.
Follow-up
The suggestions of an immunologist can be offered. The visit to a gastroenterologist is in the next three days.
Evaluation of patient encounter (Self-Assessment)
The relations between a patient and a healthcare provider have to be properly developed to promote appropriate and effective education. There are many aspects that have to be considered to ensure the success of treatment. The visit of the patient under analysis may be characterized as a normal consequence of events where a person comes to the hospital, introduces a problem, describes the complaints, and has to be diagnosed and treated properly through some shortages have to be recognized as well.
The encounter began with the representation of patient’s complaints and the details of the past medical history, including herpes two types five years ago, and a vaginal discharge diagnosed one week ago. The patient took antibiotics prescribed by the gynecologist and mentioned that diarrhea began on the seventh day of her vaginal treatment. There was enough information to begin a physical examination even though the patient did not present any family or social history. The healthcare provider asked several questions to clarify the conditions under which the antibiotics were chosen and made sure the patient took them regularly. Contact history was not discussed in communication.
The physical examination helped to gather enough information. Still, the temperature was not checked. However, it was one of the crucial symptoms that could not be ignored. Fever is the symptom of such diseases as dehydration or Enterocolitis due to Clostridium difficile. Though the patient denied fever, it could occur during the examination. Therefore, the absence of temperature data was one of the main mistakes in the patient encounter.
The evaluation of extremities and genitourinary systems was integral, and it was complete. No edema and erythema were discovered.
As soon as the main diagnosis and three differential diagnoses were given, the plan was developed. Its main point was the avoidance of any antibiotics to stop the development of gastrointestinal manifestations. In addition to this necessary, several non-medication treatment options were given, including the choice of a low-fat diet and the usage of probiotics to promote the natural balance of the intestinal tract. Probiotics include the bacteria that may prevent the development of such harmful bacteria like C. difficile. Also, it is possible to underline the importance of a healthy lifestyle and movements (Saxena, 2015).
In general, the examination of the patient was properly developed and explained. The necessary information was gathered and discovered. The patient has enough chances to pass treatment and solve the health problem. The only recommendation that has to be followed is the avoidance of antibiotics that cause diarrhea. The consideration of the lactose level is also important. The usage of dairy products has to be controlled as well in order not to provoke new cases of diarrhea or dehydration.
References
Barr, W., & Smith, A. (2014). Acute diarrhea. American Family Physician, 89(3), 180-189.
Farthing, M., Salam, M.A., Linberg, G., Dite, P., Khalif, I., Salazar-Lindo, E., … Krabshuis, J. (2013). Acute diarrhea in adults and children: A global perspective. Journal of Clinical Gastroenterology, 47(1), 12-20.
Misselwitz, B., Pohl, D., Fruhauf, H., Fried, M., Vavricka, S.R., & Fox, M. (2013). Lactose malabsorption and intolerance: Pathogenesis, diagnosis and treatment. United European Gastroenterological Journal, 1(3), 151-159.
Polage, C.R., Solnick, J.V., & Cohen, S.H. (2012). Nosocomial diarrhea: Evaluation and treatment of causes other than Clostridium difficile. Clinical Infectious Disease: An Official Publication of the Infectious Diseases Society of America, 55(7), 982-989.
Saxena, R. (2015). Women’s health – Leading a healthy lifestyle. Science Reporter, 52(3), 14-18.
Sinclair, A., Xie, X., Saab, L., & Dendukuri, N. (2016). Lactobacillus probiotics in the prevention of diarrhea associated with Clostridium difficile: A systematic review and Bayesian hierarchical meta-analysis. CMAJ Open, 4(4), 706-718.
Surawicz, C.M., Brandt, L.J., Binion, D.G., Ananthakrishnan, A.N., Curry, S.R., Gilligan, P.H., … Zuckerbraun, B.S. (2013). Guidelines for diagnosis, treatment, and prevention of Clostridium infections. The American Journal of Gastroenterology, 108(4), 478-498.