Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, July 10, 2008

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)
Really though, how often do you see an HPI with all those possible etiologies for acute diarrhea?


At Thu Jul 10, 08:38:00 AM, Blogger mark's tails said...

wow, which one or two or three of those was the red herring?

At Thu Jul 10, 09:55:00 AM, Blogger CrankyProf said...

"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.

At Thu Jul 10, 10:10:00 AM, Anonymous Anonymous said...

Clearly she had taken Alli before visiting the fast food restaurant. ;)

At Thu Jul 10, 08:17:00 PM, Blogger Shay said...

Try shigellosis. That was MY Indian souvenir.

At Sat Jul 12, 03:07:00 AM, Blogger LicensedToILL said...

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.


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