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Assessment of Diarrhoea - Case Study

By bangnong
  • Admitted to Hospital

    Admitted to Hospital

    73 year old woman MT, admitted to orthopaedic ward

  • Surgery

    MT has surgery to repair a fractured neck of femur.
  • Post Surgical Review

    Post Surgical Review

    MT develops respiratory symptoms: cough, shortness of breath and fever and is treated for pneumonia with Tazocin for five days.
  • ~ 8:30am What Assessment Does MT Require?

    ~ 8:30am What Assessment Does MT Require?

    • Pulse
    • Blood pressure
    • Temperature
    • Respiratory rate
    As for any patient with change in clinical condition – in this case new symptom of diarrhoea.
  • ~ 9:00am An Infectious Cause of Diarrhoea is Suspected, What Actions Should be Taken?

    ~ 9:00am An Infectious Cause of Diarrhoea is Suspected, What Actions Should be Taken?

    • Consider patient placement
      side room if possible, consult with Infection Control team
    • Ensure staff and patient use hand hygiene – soap and water in this case as we suspect C difficile
    • Ensure gloves and aprons available
    • Diagnostic testing – send diarrhoeal stool to lab for C difficile testing (see the C. difficile Adult Treatment of Infection Policy )
    • Stop any medication that cause diarrhoea, and if possible stop antibiotics in use
  • ~ 12 noon Further Diarrhoea

    ~ 12 noon Further Diarrhoea

    • MT is placed in a side room as she continues to have watery diarrhoea and contact precautions with soap and water, as well as gloves and aprons are made available in the room
    -What clinical assessment is required to decide on treatment?
    i) Vital signs (P, T, BP, RR)
    ii) Abdominal examination for any tenderness or distension
    iii) Assessment of hydration status

  • ~ 12:15pm Assessing Severity of Disease

    • MT has temp of 38.8C, pulse of 90, BP 110/75, and respiratory rate of 18
    • Abdominal exam indicates mild central abdominal tenderness but no distension
    • She is mildly dehydrated

  • ~ 12:30pm What Action Should Be Taken Now?

    • IV access for administration of fluids
    • Abdominal X ray if needed
    • Ensure C difficile sample has been sent
    • Seek advice on choice of antibiotics for C difficile
  • ~ 8:00am Onset of Diarrhoea

    ~ 8:00am Onset of Diarrhoea

    1. Frequency of stool
      Type of stool
    2. Review medications to find any that can cause diarrhoea
    3. Especially laxative or enema administration
    Key question: is this likely to be an infectious diarrhoea?
  • ~ 1:30pm Medical Assessment

    ~ 1:30pm Medical Assessment

    • MT is reviewed by the F2 doctor and commenced on IV fluids, an abdominal X ray is arranged and the antibiotics for the previous chest infection (Tazocin) stopped
    • He then contacts the Registrar for advice on treatment of probable C difficile
    • Registrar shows the F2 the C difficile management algorithm and decides that the patient has non-severe disease and starts treatment with metronidazole orally (400mg TDS)

  • C difficile Result

    Microbiology contact the medical team to inform that the C difficile test is positive, ensure isolation precautions in place and give clinical advice.

  • 9:00am Further Clinical Symptons

    MT’s diarrhoea reduces in frequency over the next 48 hours, but remains watery, but the abdominal pain increases and there is now distension
    • Pulse ~ 100, BP~ 100/60, T 37C, RR 24
    • WCC = 23; creatinine = 190 (baseline 88); albumin = 16

  • 9:30am What Steps Should Be Taken Next?

    • Refer to C difficile clinical management guidance on Source
    • Reassess clinical status – she now has evidence of severe disease
    • Call for opinion from infection team, surgical team, gastroenterology team
    • Abdominal imaging now essential
      CT may now be more useful than a repeat AXR, especially as the patient’s condition suggests a very unwell, unstable patient
    • Escalation of treatment on advice from infection / GI teams
      Surgery may be considered – so contact surgeons early

  • 12 noon Input from Specialist Teams

    • CT abdomen shows colitis but no toxic megacolon or evidence of bowel perforation
    • Surgeons and gastroenterology team agree on an initial trial of conservative management and close surgical review
    • Infection team recommends IV metronidazole, high dose PO vancomycin, and review next day
    • Other additional options are available if required
    • Nutrition and hydration support are needed

  • Daily Obs

    • Daily specialist input continues until MT shows clear evidence of response, with improvement in inflammatory markers, abdominal signs, fluid and electrolyte balance
    • WCC = 20; creatinine = 170 (baseline 88); albumin = 16

  • Daily Obs

    • Daily specialist input continues until MT shows clear evidence of response, with improvement in inflammatory markers, abdominal signs, fluid and electrolyte balance
    • WCC = 18; creatinine = 140 ; albumin = 17

  • Daily Obs

    • Daily specialist input continues until MT shows clear evidence of response, with improvement in inflammatory markers, abdominal signs, fluid and electrolyte balance
    • WCC = 14; creatinine = 115; albumin = 18

  • Daily Obs

    • Daily specialist input continues until MT shows clear evidence of response, with improvement in inflammatory markers, abdominal signs, fluid and electrolyte balance
    • WCC = 12; creatinine = 112; albumin = 19

  • Daily Obs

    • Daily specialist input continues until MT shows clear evidence of response, with improvement in inflammatory markers, abdominal signs, fluid and electrolyte balance
    • WCC = 11; creatinine = 109; albumin = 21

  • Daily Obs

    • Daily specialist input continues until MT shows clear evidence of response, with improvement in inflammatory markers, abdominal signs, fluid and electrolyte balance
    • WCC = 9; creatinine = 105; albumin = 22

  • Progress

    • MT is able to have treatment rationalised to PO vancomycin and a plan is put in place to complete 14 days therapy

  • Progress

    • MT makes a good recovery, diarrhoea settles and she is discharged home with follow up in orthopaedics and primary care