CHIEF COMPLAINT: Body aches, vomiting and diarrhea.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old male, otherwise healthy, who presents today with a 2-day history of generalized body aches associated with diarrhea and nausea.
He is concerned he may be getting dehydrated and just feels like he has not been able to drink as much. He had 1 episode of vomiting today; although, he really did not have much vomiting over the past couple of days. The diarrhea, however, has been watery. It has been nonbloody. He has not been travelling anywhere recently. No camping or any other risk factors.
He denies any significant sore throat, cough or congestion. He reports some mild headache but no neck pain or stiffness. He reports some mild epigastric abdominal discomfort but no lower abdominal pain and nothing focal.
He has an allergy to ibuprofen, so he has been using some Tylenol for his symptoms.
PAST MEDICAL HISTORY: No medical history.
MEDICATIONS: None.
ALLERGIES: Aspirin and ibuprofen.
SOCIAL HISTORY: No significant alcohol or drug use.
FAMILY HISTORY: No significant illnesses.
REVIEW OF SYSTEMS: Denies any blurred vision, double vision, cough and congestion. All other systems are reviewed and as per HPI; otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 102.2, pulse 104, respiratory rate 18, blood pressure 134/68, pulse ox is 99% on room air.
GENERAL: The patient is alert and oriented x3, in no acute cardiopulmonary distress, sitting in bed.
HEENT: Head is normocephalic and atraumatic. Pupils are equal, round and reactive to light. Extraocular muscles are intact. Oropharynx is clear without erythema or exudate. He has good moist mucous membranes. His TMs are clear bilaterally.
NECK: Supple without meningismus or adenopathy.
HEART: Regular rate and rhythm without murmurs, rubs or gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rales or rhonchi.
ABDOMEN: Soft and minimal tenderness in the epigastric region without rebound or guarding. No organomegaly or masses. Positive bowel sounds. No right lower quadrant abdominal pain. No pain at McBurney point. No pain in right upper quadrant. Negative Murphy’s sign.
EXTREMITIES: Warm and dry. No clubbing, cyanosis or edema.
SKIN: No rash, petechiae or purpura.
NEUROLOGIC: No focal, motor or sensory deficits noted.
EMERGENCY DEPARTMENT COURSE AND MEDICAL DECISION MAKING: This is a (XX)-year-old who presents today with generalized body aches, fever, diarrhea and nausea. He feels dehydrated.
His initial clinical exam is fairly unremarkable. There is nothing focal necessarily on exam. I think this may be more of viral in etiology. He does not have symptoms of strep throat. He really does not have sore throat. He does not have a focal abdominal exam, so I do not think this is appendicitis or pancreatitis or acute gallbladder disease. I do not see any other focal infectious process going on either.
We did place an IV, gave him some saline, some Zofran, and some Tylenol. Because of his allergy to ibuprofen, we stuck with the Tylenol. We gave him a second liter of fluid and we observed him. He was ultimately feeling much better after the fluids and the Tylenol.
I have re-examined the patient and again his symptoms are nonfocal at this time. He was able to get up and urinate. At this point, I think he is fine going home. He feels comfortable going to home. He feels better and to follow up with his PCP for recheck and of course return if he develops any new or worsening symptoms.
He is here with his mother. They are all agreeable with the plan, will be discharged to home in stable and improved condition.
IMPRESSION:
1. Viral syndrome.
2. Gastroenteritis.
3. Dehydration.
