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December 2014: Abdomen

28 year old female dynamic positioning officers presents to your sickbay with compliants of nausea for 2 days followed by 4 episodes of non-bloody vomitus for the last 24 hours. She has not been able eat or drink anything for the last 24 hours. Some associated dizziness, abdominal cramping, dark urine, subjective fever and fatigue. Patient admits that she had some loose bowel movements, 4-5 soft bowel movements without blood or mucus, for approximately 5 days. She noted that one of her children had diarrhea one week prior with about 24 hours of vomiting. The child fully recovered without incident. She is on day 3 of her 21 day hitch offshore.

past history: sinusitis 2 months ago
past surgical history: 2 C-sections, appendectomy, and tonsils removed
family history: mother with coronary artery disease, insulin dependant diabetes; father with hypercholesterolemia
social history: denies alcohol, tobacco, or illicit drug use; lives at home with her husband and 3 children ages 2,4, and 6
meds: oral contraceptive pills, and synthroid
allergies: no known drug or food allergies

Physical Exam

  • VS: temp 100.5
  • pulse 110
  • resp 18
  • Bp 96/57
  • pulse ox 98% RA
  • 5’10” tall 150 lbs

Gen: tired, ill appearing female, NAD
HEENT: PERRL, EOMI; TM’s appear normal with normal light reflex; nares without congestion; throat without erythema, mucus membranes appear dry
Cardiovascular: tachycardia, regular rhythm, no murmur appreciated
Lung: clear to auscultation bilaterally
Abdomen: flat abdomen; hyperactive bowel sounds, mild general tenderness to palpation, no guarding or rebound appreciated, no hepatosplenomegaly
Extremities: no clubbing, cyanosis or edema
Neuro: cranial nerves II-XII grossly intact, CN IX-X are not tested

Lab Work

  • Urine
    • color: dark yellow
    • clarity: clear
    • sg: >1.030
    • glu: negative
    • ketones: 10 mg/100ml
    • bilirubin: 0.5 mg/100ml
    • urobilinogen: 2 EU
    • protein: 30 mg/100ml
    • blood: negative
    • nitrite: negative
    • leukocyte: negative

 

How would you approach this patient?

Diagnosis: Acute gastroenteritis

Treatment

hydration with oral solution or IV solution if patient cannot tolerate oral hydration symptommatic control of nausea and vomiting with antiemetics such as ondansetron or promethazine symptommatic control of adbominal cramping with antispasmotic medication such as dicyclomine or hyoscyamine consideration for isolation in sick bay until symptoms resolve, hydration is able to be maintained and diarrhea has improved

Discussion

Once you suspect that your patient has acute gastroenteritis, isolation is required due to the contaigousness of the disease. Typically gastroenteritis is caused by viruses such as adenovirus, norvovirus, rotavirus or astrovirus. Treatment for gastroenteritis is symptommatic but the most important complication to avoid is dehydration. This can be achieved with fluid and electrolyte replacement either orally or intravenously. Since those with gastroenteritis are contaigous, isolation should be considered while onboard the vessel/rig, state room cleaned with the appropriate cleaning solutions daily, and strict/frequent hand washing and sanitation be maintained. The source of the condition should also be investigated. In this patient’s case, the most likely source is from her children. However, if other cases occur, then an alternate source needs to be identified and the contamination removed. Please note that controlling diarrhea with antidiarrhea medication such as loperamide has not been shown to improve patient outcome and could potentially cause additional complications with respect to the illness.

Return to Work

  • Symptoms must be well controlled
  • No longer vomiting
  • Able to drink and maintain adequate hydration
  • Diarrhea must be less frequent and strict hand washing must be observed
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