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
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