Case 2

Case 2. Diarrhea (Acute enteric infection)

Author: Mykola Garas

Case outline

 You are a doctor-intern of a municipal policlinic. At the reception, boy A., 22 years old, a 3rd year student at a medical university, is unmarried, complains about a sudden deterioration in the state of the day before yesterday, on Saturday, while staying in relatives in the village, when there was nausea, multiple vomiting and diluted stools, increase body temperature up to 38˚С. These complaints relate to the food factor - the consumption of malnutrition. After the vomiting, the condition improved somewhat, nausea decreased, but continued to disturb the apparent general weakness, dizziness, fever to 37.3˚C, abdominal discomfort, which prevented the preparation for examinations in surgery and pediatrics, which took place these days, so decided to apply for medical assistance for examining and receiving a certificate of temporary disability. In the history of the patient - vaccinated by the calendar, chronic gastritis, chronic cholecystopancreatitis with periodic exacerbations. Congenital far-sighted astigmatism, since childhood, uses glasses. Grandmother along the maternal line and the mother of the boy suffer from peptic ulcer disease.

Examination: body temperature (axillary) 36,7˚С, skin and visible mucous membranes are pale, dry, clean, limbs with a touch of warm, tissue turgor satisfactory. The guy, when viewed in the mind, is adequate, the meningeal signs are negative, the pupils react to the light symmetrically, somewhat expanded. Above the lungs is percussion - clear sound, breathing is carried out equally on both sides, the frequency of respiratory movements is 18 / min, cardiac activity is rhythmic, tons of noisy, heart rate 88 / min. The tongue is a white-cheek stratification. In the ziva - a slight hyperemia of the back wall of the pharynx. Percussion over the stomach timpanic sound. Slight pain in palpation in the epigastrium. The Shchotkin-Blumberg symptom and the fluctuation symptom are negative. When auscultation of the abdomen is heard, intestinal noises are heard at a frequency of 10 / min. The percutaneous border of the liver according to Kurlov is 9/8/7 cm. The lower edge of the liver by linea medioclavicularis dextra 1 cm below the right edging arc. Symptoms Ker, Ortner are questionable. The spleen is not palpable.

Choices are denoted Excellent (E) / Good (G) / Poor (P)

Choice 1. Recommendation of a general and biochemical blood test and a re-examination of the next day (E), consultation of the gastroenterologist (G), recommendation  to prescribe sorbents and re-review when ineffective or degraded (P).

The next day, Andrei complaints of increase dizziness, general weakness and liquid stool three times. The guy is in consciousness, adequate, the meningeal signs are negative, the pupils react to the light symmetrically, asymmetry of the eye gaps. CBC- RBC - 4.0 T/l, Gb - 120 g/l, ESR - 4 mm/h, WBS -12.5 G/l, bands n.  - 6%, segments n. - 76%, eos. -1%, lymph. - 16%, mon. - 1%. Serum test - total protein - 73.8 g/l, urea - 3.6 mmol/l, creatinine - 67.6 μmol/l, bilirubin total - 13.6 μmol/l, bilirubin direct - 1.8 μmol/l, ALT - 0.4 μmol/l, AST - 0.2 μmol/l.

Choice 2. Consultation of a neurologist (E), consultation of the gastroenterologist (G), recommendation  to prescribe sorbents and re-review when ineffective or degraded (P).

The guy complaints of periodic dizziness, voicelessness, diarrhea. Eye gaps are asymmetric due to some omission of the right upper eyelid. Periodically there is a fine-skinned horizontal unstable nystagmus. The pupils are expanded, more than right pupil, a photo-reaction is common. The facial folds are contoured indiscriminately.

Choice 3. Direction of the patient to the hospital (E), consultation of an ophthalmologist (P), consultation of the gastroenterologist (G)

Doctors suspected diagnosis of botulism

Choice 4. Prescription of infusion rehydration therapy and fluoroquinolones oral (P), prescription of infusion rehydration therapy, sorbents and fluoroquinolones oral (P), prescription of infusion rehydration therapy and polyvalent antibotulinic antitoxin (E)

Learning Objectives

  • Leading clinical symptoms and syndromes, differential diagnosis of acute intestinal infections.
  • Differential diagnosis of AEI among themselves and with diseases of the gastrointestinal tract infectious origin.
  • Clinical management of patients with AEI.
  • Emergency conditions in acute intestinal infections.

Errors covered

  • Fixation
  • Playing the odds
  • Bravado
  • Poor communication.