Gastroenteritis in a 14-Year-Old Male Patient Essay

Patient information: A. M., a 14-year-old Caucasian male.

Subjective

• Chief Complaint: fever, nausea, multiple vomitus, and diarrhea.
• History of present illness: The patient, a 14-year-old Caucasian male, came with his mother with a chief complaint of nausea, vomiting, and changes in the stool. The condition started one day ago with vomiting after eating cake at a friend’s birthday party. In 2 hours – temperature 100,4 F and diarrhea with a strong smell, liquid, mucoid, and of greenish color. Within 24 hours, the patient vomited six times and went to the bathroom seven times. The patient cannot identify the foreign substance in vomit; the mother claims no signs of blood, brown or black color in vomit or stool. Any attempt to take some water, medication, or food end with nausea and recurrent vomiting. The mother of the patient also claimed six other children from the birthday celebration (three days ago) got similar symptoms.
• Location: ventricle and small intestine Onset – one day ago.
• Character: recurrent vomiting and diarrhea Associated signs and symptoms: gastritis and duodenitis.
• Timing: gets worse after any water or food intake.
• Exacerbating/relieving factors: the absence of water and food intake.
• Severity: 6/10.
• Current medication: no previous medication intake.
• Allergies: no known allergies.
• Past Medical History: Vaccines: HepB (2006), DTaP, Tdap (2012), Hib (September 2019), IPV, PCV, MMR (2010). PMI: tonsilitis (October 2019), chickenpox (September 2013). No surgeries.
• Social & Substance History: Studies in 8^th grade, normal performance at school. Relationship with family and peers: well. Denies smoking or alcohol intake. Lives in an apartment with his mother and father.
• Family History: mother, 45 y/o, healthy. Father, 47 y/o, has COPD. Grandfather from father’s side has HTN, AFib.
• Mental History: No history of depression or anxiety. No growth, development, and psychological issues.
• Violence History: Not known.
• Reproductive History: Not sexually active.

Review of Systems

• General: Weight is stable, with no temperature deviations, weakness, or fatigue.
• Heent: Eyes: Vision functions are symmetrical, no blurred vision, double vision, and sclerae are clear. Ears, nose, throat: Hearing is bilateral; No runny nose, sore throat, sneezing, or congestion.
• Skin: Clear.
• Cardiovascular: No chest pain, pressure, or discomfort. No visual palpitations, and extremities have no signs of edema.
• Respiratory: Breathing is calm, not shortened, with no sounds, no cough, or sputum.
• Gastrointestinal: Vomiting six times per last 24 hours, diarrhea seven times for the last 24 hours. Abdominal pain in the epigastric region, no heartburn, no blood in the stool.
• Genitourinary: Urination is painless, 3-4 times per day. Genitals with no visual signs of anomalies. Not sexually active.
• Neurological: No headache, no history of trauma, dizziness, syncope, paralysis, ataxia, aphasia, dyslexia, or numbness in the extremities.
• Musculoskeletal: Muscle contraction is symmetrical, no cramping, no muscle pain, no back or joint pain.
• Hematologic: No dizziness, anemia, no bleeding, no bruising.
• Lymphatics: Lymphatic nodes are not enlarged.
• Psychiatric: No history of depression or anxiety. Psychological issues: Sleep distribution, stress because of the condition.
• Endocrinologic: No signs of heat intolerance. No known history of polyuria or polydipsia. No growth and development issues.
• Reproductive: Not sexually active.
• Allergies: No signs of asthma or allergies.

Objective data

• General: Vital signs height 64.0 in, weight 139.0 lbs, BMI 23.9 (Norm but at risk of overweight), BP 121/65 mmhg, temperature 100.4 f, pulse 71 beats/Min.
• Heent: Eyes: Perrl, conjunctivae, sclera clear. Tms normal bilaterally.
• Tonsils & pharynx: Clear.
• Skin: Clear.
• Cardiovascular: Heart sounds S1, S2 normal; No S3, no S4, no murmurs.
• Respiratory: Chest exam reveals good air entry bilaterally. Clear to ippa with no adventitious sounds heard.
• Gastrointestinal: Abdominal exam reveals positive bowel sounds, soft, non-tender to palpation in all quadrants. Hyperactive bowel sounds. Surface palpation is painless, deep palpation identifies pain in the epigastric spot. The stool is liquid, mucosal, of green color, and strong smell.
• Genitourinary: Urination is painless, 3-4 times per day. Not sexually active.
• Neurological: Neurologic exam is unremarkable; The patient is alert and appropriate for age.
• Musculoskeletal: No deformities, full range of motion.
• Lymphatics: Peripheral nodes are not palpated, painless.
• Endocrinologic: Thyroid gland is not palpated.

Diagnostic results

Provisional diagnosis is acute gastroenteritis ICD-10 A09. Before the identification of the pathogenic agent, the diagnosis remains syndromic (Shane et al., 2017).

Assessment

Priority diagnosis in this clinical case is acute gastroenteritis (ICD-10 A09) as the patient has signs of gastritis (vomiting six times per day), enteritis (snagged stool sample: liquid, mucosal, of green color, and strong smell), and intoxication (fever 100.4 F). Acute beginning, fever, and involvement of the other children from the birthday party narrow the diagnostical search around gastrointestinal infectious disorders caused by viruses or bacteria.

Differential diagnosis:

1. Crohn’s disease (ICD-10 K50.1). A chronic disorder affects mostly the large intestine that has an inflammatory nature (Feuerstein et al., 2021). Nowadays, the pathology is more frequently met among adults and children and is believed to be multifactorial. The combination of genetic, and environmental factors, disbalance in gut microbiota, and non-regulative immune reactions lead to the initiation of the disease. Among the symptoms: are chronic abdominal pain, diarrhea, ulceration of the intestinal mucosa, and narrowing of the intestine lumen (Torres et al., 2017). Even though abdominal pain, diarrhea, vomiting (if the ventricle is damaged), fever refer to Crohn’s disease, the acute onset, stool characteristics, and the anamnestic connection with food intake (cake), and acute development of symptoms of other children, does not claim for the proposed differential.
2. Diarrhea-Predominant irritated bowel syndrome (ICD-10 K58.1). A functional disorder of the gastrointestinal tract that is interfering with the patient’s everyday life and life quality. Induced by stress, diet specialties, and possible genetic predisposition, IBS becomes a chronic disorder that is also met among children (Devanarayana & Rajindrajith, 2018). IBS has two types: diarrhea-predominant and predominant constipation. According to the diagnostic criteria, IBS must cause abdominal pain a minimum of 4 days in one month; changes in the frequency of defecation change the appearance of stool. However, the fact of the changed stool of the patient is not stress-related or diet-connected. Moreover, the episode developed fast and is the first in the patient’s history. Fever is also not a characteristic sign of IBS and cannot be caused by the irritated mechanisms of the pathogenesis.
3. Acute respiratory syndrome (ICD-10 B34.2). In the current circumstances, it is hard not to mention COVID-19 infection which initially might start with gastrointestinal symptoms such as diarrhea, fever, and vomiting (D’Amico et al., 2020). The major chain causing diarrhea is the straight alteration by the virus enterocytes. The fever and diarrhea can be explained by the viral infection; however, the patient does not have any respiratory complaints. For the precise differential, it is essential to monitor the patient’s condition in case of new symptoms’ appearance.

Plan

• Diagnostic plan: Stool testing for Salmonella, Shigella, Yersinia, C. difficile, and STEC (Shane et al., 2017).
• Treatment: non-pharmacological step zero: hygiene to break the fecal-oral chain of transmitting. First-line therapy: oral rehydration 100-120 ml more judging the number of vomiting, additionally to the daily intake (salty water, juices, other liquids). According to USPTF, it is essential to focus on long-term perspectives in children under 18 screening (Kemper et al., 2016). Health promotion includes explanation of the possible agents that cause food poisoning, the importance of hygiene (hand washing).

Reflection notes

Due to this assignment, I have comprehended gastrointestinal syndromes can be met in various pathologies in different fields of medicine. During the patient’s examination, my “aha” moment was the connection to the cake intake and the number of other children with similar symptoms. The mother provided more specific information on HPI and the characteristics of the patient’s emissions. This can be explained by the mother being more attentive and accurate. In a similar patient evaluation, I would be more accurate with examining teenagers as they are more sensitive to personal questions and doctor examinations.

References

D’Amico, F., Baumgart, D. C., Danese, S., & Peyrin-Biroulet, L. (2020). Diarrhea during COVID-19 infection: pathogenesis, epidemiology, prevention, and management. Clinical Gastroenterology and Hepatology, 18(8), 1663-1672.

Devanarayana, N. M., & Rajindrajith, S. (2018). Irritable bowel syndrome in children: Current knowledge, challenges, and opportunities. World Journal of Gastroenterology, 24(21), 2211–2235.

Feuerstein, J. D., Ho, E. Y., Shmidt, E., Singh, H., Falck-Ytter, Y., Sultan, S., & Terdiman, J. P. (2021). AGA clinical practice guidelines on the medical management of moderate to severe luminal and perianal fistulizing Crohn’s disease.Gastroenterology, 160, 2496-2508.

Kemper, A. R., Mabry-Hernandez, I. R., & Grossman, D. C. (2016). U.S. Preventive services task force approach to child cognitive and behavioral health. American Journal of Preventive Medicine, 51(4), S119–S123. Web.

Shane, A. L., Mody, R. K., Crump, J. A., Tarr, P. I., Steiner, T. S., Kotloff, K., Langley, J. M., Wanke, C., Warren, C. A., Cheng, A, C., Cantey, J., & Pickering, L. K. (2017). 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clinical Infectious Diseases, 65(12), e45–e80.

Torres, J., Mehandru, S., Colombel, J.-F., & Peyrin-Biroulet, L. (2017). Crohn’s disease. The Lancet, 389(10080), 1741–1755.