Clinical Presentation
Clinical Evaluation
Initial clinical evaluation of the patient with acute diarrhea should focus on assessment of the severity of the illness, the need for rehydration, the identification of likely causes based on history and clinical findings and the presence of complications or comorbid conditions. It is more important to consider the change in stool consistency rather than the change in stool frequency in the evaluation of a patient with diarrhea. A careful clinical evaluation is needed in order to provide a cost-effective evidence-based approach to initial diagnostic tests and treatment. A diagnostic evaluation is warranted in patients with bloody diarrhea, relatively severe illness, and who are high risk (immunocompromised or elderly).
Diarrhea in Adults - Infectious_Initial AssesmentClinical Presentation of Mild Dehydration
The patient is alert and active, and the urine output is ≥0.5 mL/kg/hr. The patient is able to perform daily activities without difficulty. The blood pressure (BP) and respiratory rate (RR) are normal, and the heart rate is ≥80 bpm. The patient has moist oral mucosa; the skin turgor is ≤2 seconds, and the capillary refill is ≤2 seconds.
Clinical Presentation of Moderate Dehydration
The patient is usually weak or lethargic, irritable, or restless but able to walk or sit; thirst is increased; and the urine output is reduced. The patient is able to perform daily activities but with limitations (eg not going to work). The patient is usually tachycardic with normal or slightly decreased systolic blood pressure (SBP) and may or may not have postural hypotension. The eyeballs are only minimally sunken; the oral mucosa is slightly dry, and the jugular venous pressure is normal or slightly flat. There is a fair amount of skin turgor and capillary refill >2 seconds.
Clinical Presentation of Severe Dehydration
The patient is inactive, unable to sit or walk, has decreased consciousness, is unable to drink and has minimal urine output. The patient is unable to perform daily activities and stays in bed or needs hospitalization. The patient is tachypneic, tachycardic, SBP is decreased by >20 mmHg and postural hypotension or shock is present. The eyeballs are visibly sunken, oral mucosa is severely dry, jugular veins are flat, and skin is cold and clammy with poor turgor and capillary refill >2 seconds.
History
Symptoms
Determine whether the symptoms are of abrupt or gradual onset, the duration, and the progression of symptoms. The onset and frequency of bowel movements, the amount of stool excreted, and if dysenteric symptoms are present (eg fever, tenesmus, blood/pus in stool) should also be ascertained.
Associated Symptoms
The frequency and intensity of nausea/vomiting, abdominal pain, cramps, myalgia, headache, altered sensorium, or fever should be asked.
Stool Characteristics
Inquire if the stool is watery, bloody, purulent, greasy, or with mucus. Blood and/or mucus in stool may indicate a bacterial or parasitic infection.
Signs and Symptoms of Volume Depletion
The signs and symptoms of volume depletion include thirst, tachycardia, orthostatic hypotension, postural giddiness, decreased urination, and lethargy.
Physical Examination
Physical Exam
The focus of the physical exam is on evaluating the patient’s hydration status. A reduction of >5% in a patient's body weight may indicate moderate to severe dehydration. Malnutrition may be present with chronic diarrhea. An audible or palpable bowel activity from increased peristalsis and perianal erythema with skin breakdown may be present.
Vital Signs
The vital signs that should be noted are the presence of postural or supine hypotension, a pulse rate >90 beats per minute (bpm) or absence of palpable pulse, a respiratory rate (RR) >21 breaths per minute, and the presence of fever.
Other Signs of Volume Depletion
The other signs of volume depletion include altered sensorium, sunken eyeballs, dry mucous membranes, absent jugular venous pulsation, decreased skin turgor, cold clammy skin, slow capillary refill, and decreased urine output.
Screening
Serious Conditions
These conditions may present as acute diarrhea with or without signs of peritonitis and should be considered in a patient presenting with acute diarrhea:
- Appendicitis
- Adnexitis
- Diverticulitis
- Inflammatory bowel disease (IBD)
- Ischemic enterocolitis
- Mesenteric artery/venous occlusion
- Peritonitis secondary to bowel perforation
- Systemic infections (eg typhoid fever)