Case study
1. Patient is 42years old male alert and oriented 4
2. Had acute diarrhea after visiting Chicago on business trip ususall 3 day per year
3. Watery loose stool for 3 days
4. Streak of blood in stool lately
5. Frequency of 8 watery loose stool per day
6. Take over the counter Kaopectate
7. Had steak and burger sandwiches
8. Had mild headache, chill and fever 101.5, fatigue, loss of appetite, light headedness, elevated pulse rate 102
9. Feeling nauseous but no vomiting yet
10. Unable to go to week and must stay close to the bathroom
11. Stomach soreness/cramp
12. Had 2 school age children
QUESTION
Some clinicians may find it difficult to explain the logic behind their clinical thinking. As you gain experience, your clinical reasoning will begin at the outset of the patient encounter, not at the end. Reflect on the clinical reasoning you used during this virtual patient encounter. Describe the steps taken to identify and interpret the key findings in this case. What are some “lessons learned” within the assessment that you can apply to your professional practice as a provider? Include the following components:
i. type 150-300 words in a Microsoft Word document
ii. demonstrate clinical judgment appropriate to the virtual patient scenario
iii. cite at least one relevant scholarly source as defined by program expectations
iv. communicate with minimal errors in English grammar, spelling, syntax, and punctuation
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In the virtual patient scenario described, the patient is a 42-year-old male who presents with acute diarrhea after a recent business trip to Chicago. The patient reports having watery loose stool for the past 3 days with a frequency of 8 stools per day, and reports streaks of blood in the stool. He has taken over-the-counter Kaopectate, reports a mild headache, chill and fever of 101.5, fatigue, loss of appetite, lightheadedness, elevated pulse rate of 102, and feels nauseous but has not yet vomited. He also reports stomach soreness/cramping and is unable to work and must stay close to the bathroom.
In this case, the first step in the clinical reasoning process was to gather a thorough medical history, including the patient’s recent travel history and symptoms. This information helps to identify potential causes of the patient’s symptoms, such as an infectious illness or foodborne illness. The patient’s recent travel to Chicago, as well as his symptoms of diarrhea, fever, headache, and nausea, suggest that he may have contracted a gastrointestinal infection, possibly from contaminated food or water.
The next step was to perform a physical examination, including a thorough assessment of the patient’s abdominal and rectal area. The presence of streaks of blood in the stool suggests a possible infectious colitis, such as Clostridium difficile (C. diff) or Shigella. The patient’s elevated pulse rate and lightheadedness also suggest possible dehydration, which can be a serious complication of diarrhea.
Finally, laboratory tests, such as stool cultures and tests for infectious agents, may be necessary to confirm the diagnosis and guide treatment. Treatment for infectious colitis may include antibiotics, as well as fluid and electrolyte replacement to prevent dehydration.
This virtual patient scenario highlights the importance of thorough medical history taking, physical examination, and laboratory testing in the diagnosis and management of acute diarrhea. As a healthcare provider, it is important to remain vigilant for potential infectious illnesses, especially in patients who have recently traveled to areas with high rates of infectious disease.
Reference:
Centers for Disease Control and Prevention. (2021). Diarrhea. Retrieved from https://www.cdc.gov/diarrhea/index.html
