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| ==Medical Therapy== | | ==Medical Therapy== |
| {{familytree/start}}
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| {{familytree | | | A01 | | | A01= Adults with chronic diarrhea (> 4 weeks)}}
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| {{familytree | | | |!| | | | }}
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| {{familytree | | | B01 | | | B01=<div style="float: left; text-align: left; height: 36em; width: 30em; padding:1em;"> '''Characterize the symptoms:'''<br>
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| ❑ Onset (congenital, abrupt or gradual) <br> ❑ Pattern (continuous or intermittent) <br> ❑ Duration <br> ❑ Stool characteristics (watery, bloody or fatty) <br> ❑ [[Fever]] <br> ❑ [[Abdominal pain]] <br> ❑ [[Weight loss]] <br> ❑ Fecal incontinence
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| ----
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| '''Obtain a detailed history:'''<br>
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| ❑ Aggravating factors ([[diet]] or [[stress]]) <br> ❑ Over-the-counter drugs or use of prescription <br> ❑ Previous evaluations (objective records, radiograms or [[biopsy]] specimens) <br> ❑ Radiation therapy or surgery <br> ❑ Factitious diarrhea (eating disorders, laxative ingestion, [[secondary gain]] or [[malingering]]) <br> ❑ Systemic disease ([[cancer]], [[diabetes]], [[HIV]], [[hyperthyroidism]]) <br>
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| ----
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| '''Elicit the epidemiological factors:'''<br>
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| ❑ Travel before the onset of illness <br>
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| ❑ Exposure to contaminated food or water <br>
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| ❑ Illness in other family members </div>}}
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| {{familytree | | | |!| | | }}
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| {{familytree | | | C01 | | | C01=<div style="float: left; text-align: left; height: 29em; width: 30em; padding:1em;"> '''Examine the patient:'''<br>
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| '''Assess the volume status:''' <br>
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| ❑ General condition <br>
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| ❑ Thirst <br>
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| ❑ [[Pulse]] <br>
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| ❑ [[Blood pressure]] <br>
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| ❑ Eyes <br>
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| ❑ Mucosa
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| ----
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| '''Perform a general physical exam:'''<br>
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| ❑ Skin ([[flushing]], [[rash]]es or dermatographism) <br> ❑ Oral cavity (ulcers) <br> ❑ Cardiovascular system (murmur)<br> ❑ Respiratory system (wheezing) <br> ❑ [[Thyroid]] (mass) <br> ❑ [[Abdomen]] ([[ascites]], [[hepatomegaly]], mass or tenderness) <br> ❑ Anorectal ([[Abscess]], blood, [[fistula]] or sphincter competence) <br> ❑ Extremities ([[edema]]) </div>}}
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| {{familytree | | | |!| | | | }}
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| {{familytree | | | D01 | | | | D01=<div style="float: left; text-align: left; height: 12em; width: 30em; padding:1em;"> '''Order routine laboratory tests:'''
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| ❑ [[CBC|CBC and differential]] <br> ❑ [[ESR]] <br> ❑ [[Serum electrolytes]]<br> ❑ Total serum [[protein]] and [[albumin]] <br> ❑ [[Thyroid function tests]] <br> ❑ [[Urinalysis]] <br>
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| </div>}}
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| {{familytree | | | |!| | | | }}
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| {{familytree | | | D10 | | | | D10= <div style="float: left; text-align: left"> '''Start altered diet:'''<br> ❑ Stop lactose products <br> ❑ Avoid alcohol and high osmolar supplements <br> ❑ Drink 8-10 large glasses of clear fluids (fruit juices, soft drinks etc) <br> ❑ Eat frequent small meals (rice, potato, banana, pastas etc) <br>
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| ❑ '''Start [[oral rehydration therapy]] or [[intravenous fluids]] depending on the hydration status'''</div>}}
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| {{familytree | | | |!| | | | | }}
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| {{familytree | | | D02 | | | | | D02 = '''Any specific obvious diagnosis through history and examination?'''}}
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| {{familytree | |,|-|^|-|.| | }}
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| {{familytree | D03 | | D04 | | D03= <div style="float: left; text-align: left; width: 30em; padding:1em;">Yes </div>| D04=<div style="float: left; text-align: left; width: 30em; padding:1em;">No </div>}}
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| {{familytree | |!| | | |!| | }}
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| {{familytree | D05 | | |!| | D05= <div style="float: left; text-align: left; height: 22em; width: 30em; padding:1em;"> '''Chronic infection (outbreaks or endemic areas)'''<br> ❑ Trial of oral [[metronidazole]] 500 mg TID for 5 days for protozoal diarrhea<br> ❑ Oral [[ciprofloxacin]] 500 mg BD X 3 days for enteric bacterial diarrhea
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| '''Medication induced:''' <br>
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| ❑ Discontinuation of the drug
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| '''Irritable bowel syndrome''' (chronic abdominal pain and altered bowel habits in the absence of any organic disorder)<br>
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| ❑ Trial of antispasmodic agents (oral [[dicyclomine]] 20 mg QID),OR <br>
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| ❑ [[Tricyclic antidepressant|TCA's]]([[amitriptyline]] 10-25 mg OD), OR <br>
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| ❑ [[SSRI]] ([[fluoxetine]] 20-40 mg OD), OR <br>
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| ❑ [[Rifaximin]]</div>}}
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| {{familytree | |!| | | |!| | }}
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| {{familytree | E01 | | |!| | E01= No resolution of the diarrhea}}
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| {{familytree | |`|-|v|-|'| | }}
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| {{familytree | | | F01 | | | F01=<div style="float: left; text-align: left; line-height: 150% "> '''Order stool analysis:'''<br>
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| ❑ [[Diarrhea laboratory findings#Fecal Weight|Stool weight]] <br> ❑ [[Diarrhea laboratory findings#Stool Osmotic Gap|Stool electrolytes and fecal osmotic gap]] <br> ❑ [[Diarrhea laboratory findings#Fecal pH|Stool pH]] <br> ❑ [[Diarrhea laboratory findings#Occult Blood|Fecal occult blood testing]] <br> ❑ [[Diarrhea laboratory findings#White Blood Cells|Stool WBC's]] <br> ❑ Stool fat: [[Diarrhea laboratory findings#Fecal Fat Concentration and Output|Quantitative]] / [[Diarrhea laboratory findings#Sudan Stain for Fat|Sudan stain]] <br> ❑ [[Diarrhea laboratory findings#Analysis for Laxatives|Laxative screen]] </div>}}
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| {{familytree/end}}
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| This management is as per the American Gastroenterological Association guidelines for the evaluation and management of chronic diarrhea.<ref name="pmid10348831">{{cite journal| author=| title=American Gastroenterological Association medical position statement: guidelines for the evaluation and management of chronic diarrhea. | journal=Gastroenterology | year= 1999 | volume= 116 | issue= 6 | pages= 1461-3 | pmid=10348831 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10348831 }} </ref>
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| ==References== | | ==References== |