Case Presentation on Acute Infectious

Diarrhea

By: Francis B. Aquino

SOM – III
A. General Data:
Patient C.M., 29 years old, Female from Sta. Maria.
B. Chief Complaint:
Loose Bowel Movement
C. History of Present Illness:
4 days prior to admission, patient was apparently well when a
sudden onset of loose bowel movement described as watery, non-
bloody, non-mucoid amounting to 200ml per episode for 3 episodes
per day. No associated symptoms of vomiting, fever, abdominal pain
were noted. Patient took Loperamide and hydrated orally with
gatorade which afforded slight relief of symptoms. Patient tolerated
symptoms and did not seek consult. Last intake of food was rice,
vegetable and milk.
During the interim, persistence of LBM was noted but was
tolerated with the help of Loperamide until 1 day PTA when the patient
developed accompanying symptoms of vomiting, undocumented fever
and abdominal pain described as non-radiating, cramping, pain scale of
5/10 associated with the timing of bowel movement relieved after
defecating.
Hours PTA, persistence of symptoms now accompanied with
slight weakness prompted consult.
 D. Past Medical History:
No previous admission or surgeries. No known comorbidities. No
known allergies to food and drugs. No maintenance medications being
taken.
E. Family History:
No known heredofamilial diseases. No other family members are
experiencing the same symptoms.
F. Personal/ Social History:
Non-smoker, non-alcoholic. She is a dishwasher at a university
canteen. Uses tap water with no purification method. Diet consists of
rice and vegetables. No known history of recent travel. Recent intake
of dairy products before onset of symptoms.
G. Pertinent Physical Examination Findings:
BP: 90/60 mmHg
PR: 105 bpm
RR: 21 cpm
Temp: 36.2 C
SpO2: 97%
Patient is seen as weak-looking, slightly pale with sunken
eyeballs and dry oral mucosa. Her chest examination result was
unremarkable. Her abdomen was slightly tense with hyperactive
bowel sounds. There was no liver or spleen enlargement.
I. Clinical Diagnosis :
1. Primary Clinical Diagnosis:
ACUTE INFECTIOUS DIARRHEA PROBABLY SECONDARY TO
AMOEBIASIS WITH MODERATE DEHYDRATION
Cues:

Diarrhea (+) Abnormally liquid or unformed stools

(+) increased frequency of stools
 (+) >200g/day of stools

Acute Diarrhea < 2 weeks from onset

Infectious Diarrhea (+) Vomiting (+) Fever (+) abdominal Pain

Parameters Moderate dehydration

Fatigue +

Thirst +

Sunken eyes +

Blood pressure Orthostatic hypotension

Respiratory rate 21 - 25
(breaths per minute)

Pulse rate (beats per ≥100

minute)a

Peripheral circulation Cold, clammy skin

Level of Lethargic
consciousness

Oral mucosa Dry

Muscle weakness Mild to moderate

Skin turgor >2 seconds

Capillary refill time >2 seconds

 Secondary Clinical Diagnosis:
ACUTE NON-INFECTIOUS DIARRHEA PROBABLY SECONDARY
TO LACTOSE INTOLERANCE WITH MODERATE DEHYDRATION
Cues:

(+) Abnormally liquid or unformed stools

(+) increased frequency of stools
Diarrhea
(+) >200g/day of stools
(+) History of Intake of dairy product

2. Acute Infectious Diarrhea Causes

3. Arriving at a Clinical Diagnosis:
According to the table mentioned above, the presence of persistent
diarrhea with vomiting, abdominal pain and fever, will yield a high
percentage of diagnosing an acute infectious diarrhea. A
 pathophysiology of diarrhea is shown to explain the symptoms of
the patient.
II. Paraclinical Diagnostic Procedures
1. Primary Diagnosis:
ACUTE INFECTIOUS DIARRHEA WITH MODERATE
DEHYDRATION
Secondary Diagnosis:
ACUTE NON-INFECTIOUS DIARRHEA PROBABLY SECONDARY
TO LACTOSE INTOLERANCE
2. Do you need a paraclinical diagnostic procedure?
Yes, a paraclinical diagnostic procedure should be done to be
able to strengthen our primary clinical diagnosis and rule out the
secondary diagnosis.
3. Paraclinical diagnostics to be done with specificity and sensitivity
Fecal Leukocytes- A meta-analysis of 15 studies with a total of
7,161 patients evaluated the utility of fecal leukocytes in
distinguishing between bacterial and non-bacterial diarrhea. In
resource-poor countries, the fecal leukocyte test, when used with a
threshold of >5 cells/hpg, had a sensitivity of 50%, specificity of
83%. Since these values are low, the fecal leukocyte test may not
be able to distinguish the etiologic cause of diarrhea especially in
ambiguous cases.
Stool Culture. Because most cases of watery diarrhea are self-
limited, testing is usually not indicated. Routine stool cultures have
low pathogen yield of 2% to <60%.30-37 The results of routine stool
cultures will usually not change management. In fact, most patients
would have already recovered by the time results are available.
Stool cultures are only indicated only for severe cases (significant
dehydration, high fever, persistent vomiting, severe abdominal
pain, dysenteric stool); high risk of transmission of enteric
pathogens (patient has a history of being a food handler);
 high risk of complications; and for epidemiologic purposes (when
there is suspicion of an outbreak that is enteric in origin). Stool
culture should be requested within 3 days of symptom onset and
before administration of antibiotics to ensure that its yield is
highest.
4. Fecalysis was done for the patient, this is done through collecting a
stool specimen from the patient within the 3 days of consultation
and admission to be examined under a microscope for any WBC’s,
Parasites or Ova’s that may lead us to a more specific diagnosis

III.
Treatment
1. Pre-treatment diagnosis:
Primary Diagnosis:
ACUTE INFECTIOUS DIARRHEA WITH MODERATE
DEHYDRATION
Secondary Diagnosis:
ACUTE NON-INFECTIOUS DIARRHEA PROBABLY SECONDARY
TO LACTOSE INTOLERANCE
2. Goals of treatment:
To be able to correct dehydration of the patient and improve
patient’s condition from Moderate Dehydration to Mild
Dehydration and then to No Signs of Dehydration. Fluid and
electrolyte replacement are of central importance to all forms of
acute diarrhea.
To be able to address the abdominal pain, vomiting and fever which
are associated symptoms for the patient.
 To address the bacterial or protozoal etiologic cause of the diarrhea.

Medications used: Benefit: Price:

Metronidazole 500 Antibiotic and 0.52 - 20.86 php

mg amoeba infections
Treatment
Metoclopramide 10 Aids in Vomiting 0.90 - 7.96 php
mg

HNBB 10 mg Aids in Abdominal 1.56 - 17.87 php

Pain
Diloxanide Furoate Amoeba infections 19.85 - 25.00 php
500mg Treatment

3. Course in the Ward and Treatment Done

1st Hospital Day

S O A P

Admission
3 days pta: Vital signs:
Rehydration with 1L PNSS to run
Noted onset of 7-8 BP: 90/60 for 1 hour
episodes of loose mmHg
bowel movement, Soft diet
non-mucoid, non- RR: 21 cpms
bloody, amounting Diagnostics
to about ½ cup per T: 36. 2
CBC, Creatinine, Sodium,
episode. No consult Acute
P: 71 bpm Potassium
done. Self- Gastroenterit
medicated with O2 sat: 95% is with Stool exam
loperamide Moderate
Awake, not in Dehydration Stool Culture
1 day pta, respiratory
persistence of LBM, distress Treatment:
now with abdominal Metronidazole 500 mg IV q8
pain and (+) Sunken
undocumented eyeballs Metoclopramide 10 mg IV
fever. (+) Dry oral HNBB 10 mg IV q8 for pain
No comorbidities mucosa
Diloxauide Furoate 500mg tab TID
 2nd Hospital Day

S O A P

Patient still Vital Signs: Acute Continue medications:

complains of BP: 110/60 Gastroenterit IVFT: Lactated Ringer’s Solution to
abdominal pain. mmHg is with run at 100 cc/hour
(+) 2 episodes of RR: 20 cpms Moderate
loose stools T: 36. 2 Dehydration Soft diet
(-) Vomiting P: 101 bpm sec. to
(-) Fever O2 sat: 98% Amoebiasis Monitor vital signs and Intake q 4
(-) Cough Awake, alert, hours
not in
respiratory Monitor Intake and Output
distress
(-) Sunken
eyeballs
Moist oral
mucosa

3rd Hospital Day

S O A P

(-) Abdominal Pain Vital Signs: Acute Continue medications:

Gastroenterit IVFT: Lactated Ringer’s Solution to
(-) Fever BP: 110/60 is with run at 100 cc/hour
mmHg Moderate Soft diet
(-) Loose stools Dehydration Monitor vital signs and Intake q 4
RR: 20 cpms sec. to hours
Amoebiasis Monitor Intake and Output
(-) Vomiting Repeat CBC
T: 36. 2

P: 87 bpm

O2 sat: 98%

Awake, alert,
not in
respiratory
distress

Moist oral
mucosa
4th Hospital Day

S O A P
(-) Abdominal Pain Vital Signs: Acute For discharge
Gastroenterit
(-) Fever BP: 110/60 is with Home medications:
mmHg Moderate Metronidazole 500 mg tab TID PO
(-) Loose stools Dehydration for 10 days
RR: 20 cpms sec. to Diloxinide Furoate 500mg tab TID
Amoebiasis PO for 10 days
(-) Vomiting
T: 36. 2 Diet As Tolerated

P: 87 bpm Proper handling of food

O2 sat: 98% Follow-up

Awake, alert,
not in
respiratory
distress

Moist oral
mucosa

IV. Prevention and Health Promotion

FINAL DIAGNOSIS: Acute Gastroenteritis with Moderate Dehydration

sec. to Amoebiasis

Transmission of pathogens that may cause acute infectious diarrhea can

be prevented by hand hygiene promotion, access to clean and safe water,
proper food handling, proper excreta disposal, vaccination, supplements, and
breastfeeding. Proper practices destroy breeding grounds for pathogens and
minimizes probable exposure to these pathogens that may enter our
digestive system and may cause acute infectious diarrhea. Also, with acute
symptoms, patient should also know how to rehydrate with oresol mixture
and proper health seeking behavior should symptoms persist.

V. References
Harrison’s Principle of Internal Medicine 20E
Harrison’s Infectious Diseases 1E
The CPG on the Management of Acute Infectious Diarrhea in Children
and Adults from
https://www.doh.gov.ph/sites/default/files/publications/CPG%20AID_Full
%20version.pdf
The Philippine Drug Price Index of 2015