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no

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1. 35-year-old man

2. comes to the clinic

3. complaining of diarrhoea

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1. 35-year-old man

middle aged men

immune system well developed

2. comes to the clinic

not severe

not need immediate treatment

maybe just small pain and uncomfortable

3. complaining of diarrhea

can due to infection (bacteria, parasitic, viral)

can due to contaminated food (infection (foodborne disease))

can due to medicine

maybe lactose intolerance

physiological factors (stress and anxiety)

mechanism of diarrhea

1. increase bowel movement

2. stress induce autonomic nervous system (sympathetic action) ==> diarrhea

category of diarrhea:

1. osmotic

present of non absorbable substance in intestine

draw water into lumen

eg: lactose intolerance

2. secretory

excessive secretion of electrolyte & water into the lumen

eg: infection ( cholera, E.coli), hormone, medication, tumor

3. motility related

abnormal GIT motility either too slow or too fast

eg: hyperthyroidism (increase motility), IBS (increase)

4. exudative

blood and pus in the stool due to inflammation

eg: Crohn disease, ulcerative

5. inflammatory

involve inflammation of intestinal lining leading to leakage of fluid , blood and proteins into gut

eg: chron disease, infection, IBD

# data[].attributes.body
1. bacteria infection

2. parasitic infection

3. viral infection

4. food poisoning

5. IBD (Crohn disease/ulcerative colitis)

6. food intolerance

allergies

lactose intolerance

celiac disease

7. drug induced diarrhea

8. endocrine disorder

9. stress and anxiety

10. pancreatic deficiency

11. IBS

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1. HOPI

s -do you feel pain anywhere

o- when you start diarrhea? , how long?

c- stool color and characteristic ( blood, pus, watery, fatty)

r- do you feel pain anywhere else?

a- fever, nausea, vomiting, weight loss, fatigue, dehydration

t - how often, is it everytime, how many time you go to toilet?

e- any medication you take?, is it something that induce you diarrhea?

s- scale (rate umconfortability)

2. PMH

any hospitalization

any surgery, any illness/allergy

any cancer (chemotherapy)

drug history (laxative, fluroquinolone)

3. SH

alcohol

smoke

dietary habit

hygiene

work

physiological trauma

4. FH

cancer?

diabetes?

hypertension?

any family member have the same symptom?

5. travel history

go anywhere before?

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1. diaphoretic - excessive sweating

2. 5 bowel movements - defecate 5 times

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1. started about 2 days ago

2. first symptom was loss of appetite while eating breakfast

3. unable to finish breakfast

4. nauseated and diaphoretic during 20-minute drive to work

5. low-grade fever and abdominal cramping when arrived at work and vomiting soon after

6. next 24 hours, 5 bowel movements with diarrhea

7. watery stool and brown without blood

8. no medical problems, no meds/supplements

9. no recent changes in diet and only home food for the last week

10. bus driver and no travel out of country and no close contacts

11. PMH, allergy and meds none

12. non smoker and no alcohol

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1. started about 2 days ago

acute

2. first symptom was loss of appetite while eating breakfast

anorexia

maybe due to infection

3. unable to finish breakfast

due to LOA

4. nauseated and diaphoretic during 20-minute drive to work

body responds to toxins and inflammation

feverish

nausea causes LOA

nausea could be due to motion sickness

5. low-grade fever and abdominal cramping when arrived at work and vomiting soon after

indicates infection, inflammatory condition or heat exposure

due to hormonal changes

vomit after cramps due to GI discomfort

cramps were due to accumulation of fluid

6. next 24 hours, 5 bowel movements with diarrhea

high volume of fluid loss

can cause dehydration

7. watery stool and brown without blood

could be secretory or osmotic diarrhea

no lesion/ulcers because no blood

no liver problem

8. no medical problems, no meds/supplements

not due to any meds or past diseases

9. no recent changes in diet and only home food for the last week

eating according to his normal daily intake

rule out traveler's diarrhea

10. bus driver and no travel out of country and no close contacts

only one experiencing diarrhea

he probably ate something contaminated by himself

11. PMH, allergy and meds none

immunocompetent

not drug-induced diarrhea

not food intolerance/allergy

12. non smoker and no alcohol

immunocompetent

no liver cirrhosis

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1. bacteria infection

2. parasitic infection

3. viral infection

4. food poisoning

5. IBD (Crohn disease/ulcerative colitis)

6. food intolerance

allergies

lactose intolerance

celiac disease

7. drug induced diarrhea

8. endocrine disorder

9. stress and anxiety

10. pancreatic deficiency

11. IBS

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1. vital signs

bp

temp

rr

pr

2. general apearance

signs of dehydrations (decreased skin turgor, dry mucous membranes, sunken eyes)

3. abdominal PE

auscultation

palpation

percussion

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temperature high

hr niormal

rr normal

bp nirmal

The abdomen is soft and diffusely tender on palpation

hyperactive bowel sounds on auscultation.

The rectal exam shows brown, heme-negative stool.

# data[].attributes.body
temperature high - infection or inflammation ( febrile)

hr normal

rr normal

bp normal

The abdomen is soft and diffusely tender on palpation

generalized (tenderness in all area of abdomen)(no rigidity or guarding)

hyperactive bowel sounds on auscultation.

increased peristalsis

rapid movement of stool

The rectal exam shows brown, heme-negative stool.

no melaena, hematochezia, no obstruction of bile duct

# data[].attributes.body
1. bacteria infection

2. parasitic infection

3. viral infection

4. food poisoning

5. IBD (Crohn disease/ulcerative colitis)

6. food intolerance

allergies

lactose intolerance

celiac disease

7. drug induced diarrhea

8. endocrine disorder

9. stress and anxiety

10. pancreatic deficiency

11. IBS

12. gastroenteritis

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FBC

stool c&s

CRP

ESR

PCR

BUSE

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1. All normal EXCEPT CRP HIGH - indicating inflammation

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Final diagnosis - acute viral gastroenteritis caused by norovirus infection

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no need to ask because the diagnosis is there brah

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PBL case 4 - acute viral gastroenteritis