Diarrhea

What questions need to be asked and what body part needs to be examined?

• I would use the mnemonic “OLDCARTS”. When did the diarrhea start? Was there recent travel? Describe the symptoms. How many times per day is the diarrhea? How long have you had diarrhea? Describe the stool (color, consistency, amount, odor), What makes it worse or better? What other related symptoms do you have? What treatments have you tried? How severe is it on a scale of 1-10? Do you use laxatives? Recent antibiotic use? What medications are you taking?
• Past medical history: Have you had this before? What other illnesses do you have?
• Family history: Does anyone else in your family have these symptoms? Does anyone have a stomach virus, IBS, Crohn’s, Colitis, gluten sensitivity, lactose intolerance?
• Social history: Do you smoke, use alcohol, caffeine, recreational drugs?

Functional Pattern- Nutrition: What did you eat today, yesterday? Any new foods? How has your appetite been? Do you have any skin issues? Have you lost weight? Are you weak or dizzy? (Dunphy, 2015).

• The patient would need a thorough GI exam- inspection, auscultation, percussion, palpation. A skin assessment would be done to check for a rash as well as neurological assessment to check for orthostatic hypotension from dehydration.
• What diagnostic tests need to be obtained and why?

Diagnostic tests can vary depending on the frequency of diarrhea, the associated symptoms, the length of time it has been going on; if occult blood is present or vomiting. Tests would include:

• BMP to assess for electrolyte imbalance
• CBC to assess for anemia or infection
• Stool culture and sensitivity to assess for parasites and bacteria or stool sample for giardia
• TSH to assess for hyperthyroidism
• ESR to assess for inflammation (Collins-Bride et al., 2017).
• How would you handle abnormal findings?

The findings will dictate the treatment. Correct the underlying issue. This could be dietary, fluid and electrolyte replacement, iron, blood transfusion, antibiotics, antithyroid agents, corticosteroids for inflammation.

For IBS, Chinese herbal medicine with acupuncture has shown to be effective for diarrhea (Yan, 2019). Drugs such as 5-HT3 antagonists are a possible treatment for IBS (Yue, 2018).

Referral to a gastroenterologist for further testing if needed.

What will be your list of differentials?

Differential diagnoses include

• Acute viral gastroenteritis
• IBS
• IBD (Dunphy, 2015)

Collins-Bride, Geraldine M. Clinical Guidelines for Advanced Practice Nursing: An Interprofessional Approach. Jones & Bartlett Learning, 2017.

Dunphy, L. M. H., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary care: the art and science of advanced practice nursing (4th ed.). Philadelphia, PA: F.A. Davis Company.

Yan, J., Miao, Z., Lu, J., Ge, F., Yu, L., Shang, W., … Sun, Z. (2019). Acupuncture plus Chinese Herbal Medicine for Irritable Bowel Syndrome with Diarrhea: A Systematic Review and Meta-Analysis. Evidence-Based Complementary & Alternative Medicine (ECAM), 1–16. https://doi.org/10.1155/2019/7680963

Yue, Ling, et al. (2018). “Comparative Effectiveness of Pharmacological Treatments for Patients with Diarrhea-Predominant Irritable Bowel Syndrome.” Medicine, 97(31), doi:10.1097/md.0000000000011682.