The chief complaint in this Ihuman case study is based on a history of Borderline HLD. The tests and the examinations have been recorded and evaluated to make sure the root cause is identified.

Below is an Ihuman Case on a suspected case of Borderline HLD.

CC: Diarrhea

HPI: The patient is a 42 year-old male who has a history of borderline HLD, who arrives to the ED with complaints of diarrhea, lightheadedness, “cottonmouth,” fever, poor appetite, diaphoresis, malaise, and crampy abdominal pain for the past three days after arriving home from a business trip in Chicago. Physical exam demonstrated poor skin turgor, tachycardia, orthostatic hypotension, dry mucous membranes, and a positive guaiac with rectal exam.

Leukocytosis present. Stool culture positive for salmonella enteritidis. C-diff test negative. Stool gram stain depicted gram negative bacilli. Fecal leukocytes >10,000. Colon biopsy cancelled due to identification of infectious etiology.

The patient denies any nausea, vomiting, chest pain, or sob.

Onset: Right before the diarrhea started about three days ago after a business trip to Chicago. Had a decreased appetite after, but attributed it to overeating.

Location: Abdomen

Duration: Constant

Characteristics: Sharp crampy pain

Associated signs and symptoms: poor appetite, lightheadedness, fever, diaphoresis, and malaise.

Timing: Three days ago

Exacerbating/ relieving factors: Pain is exacerbated when the episodes of diarrhea occur. Decreased pain after diarrhea.

Current Medications: Kaopectate

Allergies: NKDA

PMHx: Chicken pox, borderline HLD

Soc Hx: Married with two children. Drinks one glass of red wine 3-4 days a week. He does not drink or use any recreational drugs.

Fam Hx: Father has HTN. Mother has no issues. Unaware of grandparents history

General: Appears diaphoretic and in discomfort

HEENT: Headache present. Lightheaded. No double vision, or eye trauma. No recent hearing

loss or changes. Denies nasal congestion, post nasal drip, or nose bleeds. Maintains that all teeth are intact, with no ulcers, tooth problems, or bleeding gums. No hoarseness or sore throat. Hearing loss.

Integument: No lesions or rash

Neck: No prior injuries or issues with pain.

Respiratory: No cough, dyspnea, or shortness of breath.

CV: She does not have any known murmurs or palpitations. No known arrhythmias. No exercise intolerance.

GI: No nausea. Abdominal pain and tenderness. No heartburn, nausea, vomiting, or indigestion. Abdominal distention. No history of constipation. Normal weight. Diarrhea. Lack of appetite.

GU: NO known dribbling, urgency, or frequency.

MS: No known joint pain, swelling, arthritis, or muscle pain outside of the chest pain. Full range of motion. No traumas or fractures.

Hematologic: No bleeding, bruising, or anemia.

Lymphatics: No lymph node enlargement. No history of splenectomy.

Psych: No history of anxiety, paranoia, and depression. No history schizophrenia or bipolar. No history of suicide or homicide.

Neuro: No history of a loss of consciousness, weakness or fainting. Headaches. No memory loss and confusion. Denies gait changes. No history of falls.

Endocrine: The patient does not suffer from heat/cold intolerances. No hormone therapies or endocrine symptoms.

Allergic/Immunologic: NKDA.

Physical exam:

General: Appears distressed and diaphoretic

HEENT: PERRLA/EOMI, no nasal drainage, head is normocephalic, symmetrical, atraumatic, dry mucous membranes. Oropharynx and external ears unremarkable. Normal conjunctiva.

Neck: No palpable masses. Supple, symmetrical, trachea midline. No thyromegaly or lymphadenopathy

Chest/Lungs: Normal breath sounds. Chest rises symmetrically. Normal breath sounds. Normal respiratory effort. No accessory muscle usage. No cough present.

Heart/Peripheral Vascular: Tachycardia. Normal S1/S2. No murmurs. No JVD noted. Radial pulses+2. Normal capillary refill in toes.

ABD: Hyperactive bowel tones. Moderate distention. Abdominal tenderness. No masses noted. No rebound tenderness. No recent weight loss. Diarrhea. Positive guiac with rectal exam

Musculoskeletal: muscle strength equal, and intact in bilateral upper and lower extremities. No bone deformities. No peripheral edema

Neuro: Cranial nerves 2-12 noted to be intact. Normal deep tendon reflexes.

Skin/Lymph Nodes: No mottling. Moderate skin turgor,some tenting, no other blemishes. No clubbing present. No palpable lymph nodes. No bruises, rashes, or petechial on exposed skin

Primary Diagnosis:

Status/Condition: Infectious colitis secondary to salmonella enteritidis enterocolitis Code Status: Full code

Admit to Unit: Medical unit Activity Level: Stand by assist Diet: Clear liquids

IVF:

Two liter fluid bolus
LR at 125 ml/hr continuous

Critical Drips

None

Respiratory:

Keep O2 saturation >90%

Diagnostic/Laboratory results:

WBC 13.500 mm3
Band cells 10%
BUN:Cr ratio= 20.1
Stool culture (+) for salmonella enteritidis
C-diff (-)
Stool gram stain:gram negative bacteria
Fecal leukocytes >10,000 WBC/mcl
Colon bx: cancelled

Medications:

Ciprofloxacin 500 mg bid
Acetaminophen 650 mgq6hrs for fever

Nursing Orders:

Encourage patient to drink fluids
Assess vitals q4hrs.
Orthostatic blood pressure shift.

Follow Up Lab tests:

Consults:

GI consult for treatment and evaluation of symptoms

Patient Education and Health Promotion(address age appropriate patient education if applicable):

Infectious colitis
Diarrhea
Dehydration

Discharge planning and required follow-upcare:

Primary care one week post-hospitalization

Differential diagnoses:

Toxin induced colitis
Inflammatory bowel disease

References

Carden, S., Okoro, C., Dougan, G., & Monack,D. (2015). Non-typhoidal Salmonella Typhimurium ST313isolates that cause bacteremia in humans stimulate less inflammasome activation than ST19 isolates associated with gastroenteritis. Pathogens and Disease, 73(4). https://doi- org.ezp.waldenulibrary.org/10.1093/femspd/ftu023

Ngogo, F. A., Joachim, A., Abade, A. M., Rumisha, S. F., Mizinduko, M. M., &Majigo, M. V. (2020).

Factors associated with Salmonella infection in patients with gastrointestinal complaints seeking health care at Regional Hospital in Southern Highland of Tanzania. BMC Infectious Diseases, 20(1), 135. https://doi-org.ezp.waldenulibrary.org/10.1186/s12879-020-4849-7

Yeung, C. C., Hockenbery, D. M., Westerhoff, M., Coutre, S. E., Sedlak, R. H., Dubowy, R. L., Munugalavadla, V., Taylor, K., & Bosch, F. (2018). Pathological assessment of gastrointestinal biopsies from patients with idelalisib-associated diarrhea and colitis. Future Oncology (London, England), 14(22),2265–2277. https://doi-org.ezp.waldenulibrary.org/10.2217/fon-2017-0528

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Borderline HLD Ihuman Case Study