Too Much History
Many people will claim that there's no such thing as "too much medical history" when trying to diagnose a patient. Technically I agree with that statement, but there are times when too many clues make things harder instead of easier:
Saw a 20-something lady the other day with a three-day history of watery diarrhea; 10-12 stools per day; no blood; no nausea, no vomiting, no abdominal cramping; slight fever (100.2 in the office); otherwise unremarkable physical exam; stool frequency decreasing.
More history:
Symptom onset was about 4 hours after consuming a meal at a fast food restaurant, which included tomato products. Note: source of a national tomato/salmonella scare not yet figured out.
Some more history:
Said fast-food meal was consumed approximately 12 hours after returning from a 10 day business trip to India.
Even more history:
Having misunderstood the instructions given to her about the ciprofloxacin pills she was given to take IF SHE HAD SYMPTOMS while in India, she had in fact taken them twice a day for 10 days on the trip despite feeling perfectly fine. (She thought they were to prevent diarrhea.)
So which is it?
- bacterial colitis, possibly salmonella, from the fast food restaurant
- bacterial or viral gastroenteritis acquired in India (cholera? vibrio? campylobacter? other weird parasite?)
- antibiotic-associated colitis, possibly C. diff, from the cipro
- none of the above (garden variety everyday viral gastroenteritis)
posted by #1 Dinosaur @ 5:21 AM
5 comments
5 Comments:
wow, which one or two or three of those was the red herring?
"Delhi Belly?"
Did the restaurant area report any other cases of salmonella?
I'd assume that the antibiotic-associated colitis would have surfaced earlier (by day five of the pills)? Is the characteristic smell of c-diff present?
I'm guessing you sent out a poo culture.
Clearly she had taken Alli before visiting the fast food restaurant. ;)
Try shigellosis. That was MY Indian souvenir.
Decreasing frequency before a sudden increase maybe. Perhaps she was just pooped out.
The timing of the onset of symptoms is key, no? Cipro induced gastro-E would have been sooner.
I've had salsa from pollo loco that gave the whole ER some funky gastro-e. (thank you drug reps)
C-dif is as crankyprof said- uniquely vile (meaty to me)
Barely qualified guess: I think it's c-dif from comida in India, exacerbated by a sudden return to the fatty molecules known as American fast food.
I love to hear you thinking about this stuff- reading your thought process is real learning for a new nurse.
Cheers
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