Full Answer Section

• • Hydration status: How much fluid has he been able to keep down? Any lightheadedness, dizziness, or decreased urination?
  • Past medical history: Any history of inflammatory bowel disease, irritable bowel syndrome, or other GI issues?
  • Medications: What medications is he currently taking?
  • Social history: Any sick contacts?

• Physical Exam:

  • Vitals: Temperature, heart rate, blood pressure, respiratory rate, and oxygen saturation. The elevated heart rate and temperature are concerning for dehydration and/or infection.
  • Hydration assessment: Check for skin turgor, mucous membrane moisture, and capillary refill.
  • Abdominal exam: Assess for tenderness, guarding, rebound tenderness (signs of peritoneal irritation), and bowel sounds. While he has general tenderness, the absence of rebound/guarding is reassuring.

• Differential Diagnosis:

  • Viral gastroenteritis (most likely given the presentation)
  • Bacterial gastroenteritis (e.g., Salmonella, Campylobacter, E. coli)
  • Food poisoning
  • Inflammatory bowel disease flare-up (less likely given the acute onset)
  • Irritable bowel syndrome (less likely given the acute onset)
  • Medication side effect

Investigations:

• Stool studies: If symptoms persist or worsen, or if there’s blood in the stool, I would consider stool cultures, ova and parasites exam, and C. difficile toxin assay.
• Electrolytes: If there are concerns about dehydration, checking electrolytes (sodium, potassium, etc.) is important.

Management:

• Hydration: This is the most crucial aspect of treatment.
  • Oral rehydration: If he can tolerate oral fluids, I would recommend oral rehydration solutions (ORS) like Pedialyte or Gatorade. Small, frequent sips are best.
  • IV fluids: If he is significantly dehydrated (e.g., unable to keep down fluids, signs of dehydration on exam), IV fluids would be necessary.
• Symptomatic relief:
  • Antiemetics: For nausea and vomiting, I might consider an antiemetic like ondansetron (Zofran).
  • Antidiarrheals: Generally, I would avoid antidiarrheals like loperamide (Imodium) in acute infectious diarrhea, as they can prolong the illness. However, in certain situations (e.g., if the diarrhea is very severe and causing significant discomfort), they might be considered cautiously.
• Diet: A bland diet (BRAT diet – Bananas, Rice, Applesauce, Toast) or clear liquids may be helpful initially. As he improves, he can gradually advance to a more regular diet.
• Monitoring: I would monitor his symptoms, hydration status, and vital signs closely. If his condition worsens (e.g., worsening dehydration, persistent fever, bloody stools), he would need further evaluation and management.

Patient Education:

• Emphasize the importance of hydration.
• Discuss hand hygiene to prevent the spread of infection.
• Advise him on when to seek further medical attention (e.g., worsening symptoms, signs of dehydration, blood in stool).

Disposition:

Most likely, this patient can be managed at home with oral rehydration and symptomatic treatment. However, if there are concerns about dehydration or other complications, hospitalization might be necessary.