Doorway information about patient
The patient is a 34-year-old man who comes to the clinic
complaining of 4 weeks of diarrhea.
Vital signs
Temperature, 98.0 F (36.7 C)
Blood pressure, 118/78 mm Hg
Heart rate, 86/min
Respiratory rate, 14/min
History
HPI
Please explain what you mean by diarrhea.
How many times a day are you going?
Do you have a large volume or small volume?
When did the diarrhea start (differentiate between acute and chronic)?
What is the pattern of diarrhea? Do you have episodes of normal bowel
movement in between (continuous or intermittent)?
How often do you have diarrhea?
Does the stool have blood?
Is there pus or mucus in the stool?
Is the diarrhea greasy with fat on top?
Do you have abdominal pain (inflammatory bowel disease and irritable bowel
syndrome)?
Have you lost weight (malabsorption or malignancy)?
Is the diarrhea triggered by anything you are eating (eg, milk products for
lactose intolerance)?
Have you had increased stress recently?
Does anything make your diarrhea worse?
Does anything make your diarrhea better?
Do you have a history of recent travel?
Do you have any sick contacts?
Have you had fever or chills?
Past medical
history
Have you had a similar problem before?
When was it diagnosed and treated?
Have you been diagnosed with any other medical conditions by a doctor (eg,
diabetes, HTN)?
Have you had any surgeries?
Have you been exposed to any radiation in the past?
Medications/
allergies
Do you take any medications (prescription and over-the-counter)?
Are you allergic to any medications?
If so, what reaction do you have?
Family history
How old are your father and mother?
Do they have any medical conditions?
How old are your brothers and sisters?
Do they have any medical conditions?
Social history
Who do you live with?
What kind of work do you do?
Do you smoke? At what age did you start and how much do you smoke?
Do you drink alcohol, including beer? How much and how often?
Do you use recreational drugs (IV drugs)?
Physical examination
General
Wash your hands.
Perform proper draping techniques.
Examine without the gown, not through the gown.
HEENT/
Neck
Examine oropharynx for any lesions.
Palpate neck for enlarged cervical lymph nodes, thyromegaly, and masses.
Cardiac
Auscultate for murmurs, rubs, or gallops.
Lungs
Adomen
Auscultate lungs.
Auscultate for bowel sounds.
Percuss for bowel gas pattern.
Palpate abdomen both superficially and deeply.
Conclusion
Summarize history and findings.
Counsel patient on the following:
Explain physical examination findings.
Explain differential diagnosis.
Explain the next steps in workup.
Differential diagnosis
Secretory diarrhea (bacterial toxins, ileal bile acid
malabsorption, endocrine diarrhea)
Osmotic diarrhea (osmotic laxatives, carbohydrate
malabsorption)
Inflammatory diarrhea (inflammatory bowel disease,
infectious diseases - Giardia)
Fatty diarrhea (celiac disease, short bowel syndrome)
Investigations
CBC with differential
FOBT
Comprehensive metabolic panel
Serum TSH
Stool studies (eg, WBC, O+P)