Transcript Salmonella Enterocolitis Teaching case

Case Presentation
Acute Diarrhoea
Mr AB
• 24 yo man lives interstate
• Presents with 3 days diarrhoea and 4 days
abdominal pain and feeling generally unwell.
• 12-15 episodes of diarrhoea a day
– normal colour
– not watery but loose ++
– no blood or mucous
• Generalised non-specific crampy abdo pain,
right worse than left, radiating to right back.
– worst pain ever experienced like ‘stomach in a vice’
• No vomiting, no fevers/sweats/rigors.
• Loss of appetite.
Past Medical History
• Gastroenteritis one year ago – 24 hr bug
• Gastritis – 18yo – took Somac for a while
Medications
• No medications or allergies
Family History
• Parents and sister (25) well
Socially
• No infectious contacts,
• Just quit smoking 3 pk/wk, w/e ETOH binges
• Ate a ‘dodgy’ chicken schnitzel on Friday at
shopping centre
Examination
• HR 100, BP 100/70, T 364, RR18, Sats
100%RA
• Looks unwell but not distressed or haemodyn.
compromised.
Soft abdo
Right sided and bilateral IF
tenderness
No renal angle tenderness
Mild RIF rebound
No organomegaly
BS increased
Examination II
• Stong Pulses, Dual Heart Sounds, no
murmurs
• Chest Clear
• MMM, normal turgor, warm to touch,
appears well perfused, thirsty
• FWT – NAD
• BSL – 4.6mmol
FBE
Other Bloods
Abdo XR
Questions
• Any other questions or examination
points?
• DDx?
• Plan?
Progress
• Analgesia
– Pain well treated though not completely
relived by Panadol and Buscopan
• IV Fluids
– HR 75, BP 120/80, T 373
• Admit Surg – Single Room
– Observe ?appendicitis DDx gastroenteritis
• Faecal Spec for MCS collected in ED
– Loose brown sample, occasional WCC, RBC+
• Overall feeling much better on PM WR.
21/7/2006 – AM WR
• Little change:
– few bouts of diarrhoea overnight
– crampy abdo pain persists on right side
though not guarding as was yesterday
– still no temperature above 373
– feels hungry
• Dilemma:
– definitive diagnosis of appendicitis can
really only be made on laparoscopy
– What to do now?
Repeat Bloods
Repeat Bloods
CT Abdo/Pelvis
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CT Report
• Severe right sided colitis extending from
caecum to hepatic flexure.
• No terminal ileitis.
• No skip lesions.
• Suggest biopsy!!!!
AXR Report
• No soft tissue definition.
• Some ‘loss of definition’ within the right
sacroiliac joint.
• ? inflammatory arthropathy.
Further History
• Frequently gets sore knees and shoulders from
time to time.
– blames it on football
• Back pain occasionally
– when standing for long periods
– doesn’t know if always worse on right
• No chronic diarrhoea.
• No history of red eye, skin complaints, nonaxial joint pain, redness or stiffness, no mouth
ulcers, no other extra-intestinal
manifestations of IBD.
Progress
• Diarrhoea and pain settled and patient
tolerating FWD at day two admission.
• Back pain occasional and mild.
• Gastro Med Review:
– no active treatment required at this stage if
symptoms improving
– requires gastro and rheum f/u
– otherwise can go home
– will need colonoscopy in 4-6 weeks
• GP in Newcastle was contacted.
• D/C three days after admission.