Gastroenteritis Case
Name – Kyle Tucker
12/03/89
Kyle Tucker a 25 year old student had episodic diarrohea for the past 2 days and has colicky abdominal
pain before the diahorrea comes on. He also has nausea but hasn’t vomited.
DIarrohoea 5-6 times Lost his appetite as well. Her friend also has similar symptoms and they both ate
from the same restaurant 3 days ago.
Current Medical History
Not on medication
PMH
Had appendix removed about 5 years ago.
Family History
No significant Family history
Social History
Lives on campus in hall of residence, Has about 2-3 standard drinks per week, Non smoker, no stress
ICE
Most probably caused by the restaurant food.
Worries about seriously long term complications and diffuclut in leaving the house due to the need to
use the toilet all the time.
Wants to get the problem fixed as soon as possible.
QUESTIONS
Introduction
1. Name, Role, Permission, confirm confidentiality. How would you like me to address you?
Date of birth?
2. What has brought you here?
Examples of Presenting complaints . Take HPC for each symptom.
Do you have nausea & vomiting? In Gastroenteritis Children (vomiting usually 1 day,
diarrhoea 5 to 7 days)
Do you have diarrohea? In Gastroenteritis (Loose, watery stools are usually passed three or
more times within 24 hours,the stools may contain traces of blood and mucus).
Associated symptoms for this case
Do you Stomach pain?
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SOCRATES
(Site, Onset, Character, Radiation, Associated symptoms, Timing, Exacerbating/Relieving
Factor, Severity)
Do you fever?
Do you feel tired/energy?
Ask about Dehydration Symptoms:
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Malaise, apathy (a lack of emotion or enthusiasm), dizziness, nausea, headaches,
muscle, cramps, dry mouth, sunken eyes, Decrease urine, rapid heartbeat, Refill, in
children fewer tears when crying.
Other questions specific for this case?
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Have travelled anywhere recently
Have you eaten anywhere else
Does anyone else you know been feeling the same way
If female, check for pregnancy signs.
Current Medical History
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Do you have any diseases like high blood pressure, diabetes or disease?
Are you on any medication? If yes.. Drug
Dose
Frequency
Indication
Do you have any allergies?
Are herbal medicines?
Past Medical History ( PMH )
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Do ever been severely ill before? Have you ever been hospitalized (surgeries - major
operations and ask for any anaesthetic problems)?
Family History
Is there any illness running through your family?
Social History
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Current living situation&Support
Diet&Exercise
Smoking. How much& for how long
Alcohol. How much & for how long
Occupation
Recreational Drugs
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Do you have any ideas about your condition
Do you have any concerns
Do you have any expectations
ICE