Acute Diarrhea Diagnosis for New Nurse Practitioners
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Show notes:
Acute diarrhea is SUCH a common chief complaint in primary care. In this week’s video I’m covering acute diarrhea diagnosis for new nurse practitioners in primary care.
Acute Diarrhea Diagnosis in Primary Care
Including:
✅ The approach to diagnosis
✅ What “doorways” to keep track of
✅ The most important history questions
✅ Triaging the most dangerous presentations
✅ Whether to order labs or not!
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well hey there it's liz rohr from real
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world np and you're watching mp practice
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made simple the weekly videos to help
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save you time frustration
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and help you learn faster so you can
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take the best care of your patients
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so in this video i'm going to be talking
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about acute diarrhea
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um and so if that is not your cup of tea
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feel free to move along
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if you're a provider uh unfortunately
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this will come up quite often so you
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might want to stick around but if you're
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not a healthcare provider
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you can feel free to pass on this one in
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this video i'm going to be talking about
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the general approach to diagnosis and
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the important considerations to have
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in your work up in primary care and a
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second separate video
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next week i'm going to be talking about
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the individual pathogens and what to
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watch out for
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in each i tried to make it as one video
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and it was super super long so that's
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what i'm doing too so when it comes to
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the classification
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um i like these anchoring kind of pieces
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of information
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so acute diarrhea is considered to be
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less than 14 days
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14 to 30 days is considered to be
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persistent
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acute diarrhea and greater than 30 days
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is considered to be
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chronic so chronic diarrhea is actually
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a separate topic
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separate differential diagnosis so i'm
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really just focusing on acute in this
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video
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when it comes to this workup you really
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want to think about
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the overarching causes as well as the
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other potential body systems to think
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about
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so the main overarching causes are
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infectious whether it's viral bacterial
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parasitic
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or inflammatory the things you want to
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ask about in your visit i always start
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with old cart right that framework if
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you've been following me for a while you
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know what i'm talking about but
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onset location duration characteristics
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associated factors relieving factors and
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time and any treatments that they've
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done
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as my general anchoring for my history
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taking you also want to consider though
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the other
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associated body systems especially if
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you're not quite sure what you're
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looking for
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in terms of your your broad differential
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diagnosis because i have to say when it
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comes to acute diarrhea
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most of the time in primary care it's an
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acute viral gastroenteritis
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however the differential is really broad
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and it includes some red flags so it's
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important to
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make sure that you're not being
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influenced by cognitive bias
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thinking that oh of course this is what
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this is here's all the evidence why
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you really want to keep that skeptical
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perspective of why is it not that
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until it is right so if you're not sure
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what questions to ask
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um asking the full ros for the whole gi
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system
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and then the associated body systems for
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any gi complaint so gu
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all of those ros questions cardiac and
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respiratory as well
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as well as general in terms of like the
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fever and chills weight loss things like
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that that's kind of gi
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as well but it also isn't under
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constitutional
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general ros so some history questions i
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really want to highlight
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and i'm looking down because i have my
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notes here and i don't want to forget
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about anything you specifically want to
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ask about those red flags and those red
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flag symptoms will really allow you
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right away to triage how serious of an
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issue this is
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so those for when it comes to diarrhea
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those are fever blood and stool
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mucus in stool watery diarrhea versus
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loose they're both concerning and watery
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doesn't necessarily mean it's
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imminently dangerous but the more
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dangerous ones tend to have
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watery diarrhea compared to looser stool
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and you also want to ask about signs of
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volume depletion so
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do they have symptoms of orthostasis do
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they have dizziness when they stand up
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when they change positions do they have
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dry mucous membranes
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things like that those are the most
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alarming things and if you don't have
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any of those alarming things most of the
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time
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you can rest easy however one actual one
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other one i want to make
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is abdominal pain and the reason i say
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abdominal pain
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is because it's not necessarily a red
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flag but the really important thing to
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think about
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is that actually it might not be
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diarrhea
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maybe they're coming in as diarrhea as
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their primary chief complaint
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however the underlying etiology might
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change
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in that you could have something like an
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appendicitis
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with abdominal pain and diarrhea but
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they're only coming in for a diarrhea so
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i think it's just really important to be
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mindful
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if they have any of those initial red
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flags or
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they have abdominal pain abdominal pain
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you just really want to widen the lens
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of what you're looking at when it comes
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to differential diagnosis
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so this is another one of those videos
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that is a very overarching video because
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there's so much to say
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and this is the way that i approach
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primary care in general
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is that when it comes to cheap
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complaints especially of primary
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care very common presentations i know
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the general the general questions to ask
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that will lead me to the most common
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things
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and i also know what are those doorways
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that will
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allow me to think about another
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differential diagnosis right so those
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are my kind of like triage doorway
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questions to start
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blood and stool fever mucous and stool
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any abdominal pain and wear uh and is it
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watery is it loose especially if there's
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more than six
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in 26 episodes in 24 hours
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those things are those doorways of like
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okay if you have any of those go down
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that pathway look at your resources and
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refresh your memory
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about what are the potential
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differential diagnoses we're looking for
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for those red flag scenarios because our
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job is not to memorize everything and be
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a walking text
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textbook as much as i'd like to be
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that's not our job our job is to give
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safe and effective care
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and if common things appear commonly i
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remember all of those things and i also
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know
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what are the cues to continue to utilize
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my resources as well as look
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up further things right so i just want
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to say that as
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as a as a kind of like overarching
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disclaimer for this video because it
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really is an
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overarching approach and if you
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encounter any of those
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doorways uh those are the paths to lead
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down up to looking up specifically what
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is diarrhea with blood
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blood in stool what are the potential
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differential diagnoses for that scenario
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right
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some other important history questions
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you want to ask that are not necessarily
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alarm
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signs but they're really important when
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it comes to generating your differential
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diagnosis
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so again do they have abdominal pain
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where is it
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uh what was the history of the pain
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development like did it start the
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umbilicus and go to the right lower
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quadrant
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appendicitis anyone um so history of
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recent exposures
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history uh you know medications that
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they've had antibiotics proton pump
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inhibitors
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travel foods uh where do they live
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occupation as it relates to you know do
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they work in a daycare
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do they work as a food service worker do
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they work as a health care worker their
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exposures might be a little bit
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different
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pets and hobbies and i'm smiling a
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little bit talking about that because i
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don't know off the top of my head what
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animals can cause what infections
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but i know depending on their
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presentation
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most of the answers to all of these
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things is no typically
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when somebody comes in with diarrhea
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it's usually a viral gastroenteritis and
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all of these are nose
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but at least we've asked right and so if
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they have some some pets at home they
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have
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and you know salamander at home we can
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think about
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is that contributing is that a
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contributing factor at all you know
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salmonella is common with
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exposure to animals sexual practices is
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also really important so
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um so uh oral rectal
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or rectal insertive um intercourse
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can predispose exposure to certain
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bacteria so those are important things
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to think about
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some really other important things to
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think about in terms of the higher risk
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patients and higher risk scenarios
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again more doorways if they have more
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which i already kind of mentioned but if
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they have more than six episodes of
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watery stool
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in the last 24 hours severe abdominal
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pain or signs of hypovolemia those are
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really concerning
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because they're at risk for dehydration
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they're at risk for decompensation
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and of course abdominal pain is fit
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severe is at risk for higher red flag
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diagnoses
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mesenteric ischemia might present with
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diarrhea
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and abdominal pain that's out of
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proportion with their physical exam
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right but it's not the diarrhea that's
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the underlying thing it's a symptom of
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the mesenteric
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ischemia for example again signs of
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inflammatory diarrhea
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blood mucus in stool or fever high risk
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patients you want to be really careful
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with them
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so if they're over the age of 70 if they
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have underlying cardiac disease and the
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rationale for that is that they're more
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sensitive to fluid status changes so if
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they get dehydrated
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they need iv fluids that could put them
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into heart failure or require
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hospitalization more than somebody who
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doesn't have an underlying cardiac
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disease if they're
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immunocompromised especially if they
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have or in addition to
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severe hiv with a low cd4 count those
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patients have
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that's another doorway there because
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those patients have additional
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considerations in terms of pathogens
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that they might potentially have
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compared to somebody else with a
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with an immune system that is not
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compromised if they've had symptoms
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greater than a week that is definitely
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concerning as well
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and then again things to keep in mind if
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somebody's a daycare worker a healthcare
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worker
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a food service worker um they
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potentially you just want to be more
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careful with their diagnosis because
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they could be spreading it to other
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people or they could be exposed to other
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things that other people aren't
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so the next steps after the history are
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looking at the abdominal exam and it's
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really the same as any other abdominal
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exam right so you're looking for
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is there distension is there severe pain
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is there guarding is there rebound signs
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of peritonitis signs of an ileus
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signs of blockage things like that all
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of the regular stuff that you're looking
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for in an abdominal exam and any of
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those red flags definitely lead you down
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that red flag differential diagnosis
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path so in patients who don't have
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severe symptoms or are in that high risk
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category most of the time they can get
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away with supportive care
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and observation so adequate hydration
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with them
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some sort of not just plain water that
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has some sort of solute in it where
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it's either an oral rehydrating solution
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hydrolyte
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and i'm not affiliated with any of these
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brands but hydrolyte is an example
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powerade and gatorade are more of like a
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sweat replacement um
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electrolyte drink and they have a lot of
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sugar but that is also an option to
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whatever they can kind of keep down
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some people talk about loperamide or
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other
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antidiarrheal agents and it's really
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conflicting whether or not those are
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recommended
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some people find them to you know can
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decrease the
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duration of the illness by about a day
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or so but also there's some evidence
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that it can lead to
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trapping of of liquid in the small
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intestine
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potentially this was very like
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preliminary stuff that i found so
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anybody who takes those
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needs to follow the directions and not
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overdose on them and make sure that
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they're also drinking adequate hydration
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having had adequate hydration adequate
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fluid intake because there can be some
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hidden fluid losses
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because of that i i have a conversation
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with the patient if there's any high
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risk things i want to investigate that
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further
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before i consider any kind of treatment
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and i usually recommend
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unless they're really having a hard time
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with it to generally avoid those
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because anytime you introduce
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medications there's always risk for side
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effects right so in terms of the further
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work up i think
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i think myself as a new guide and every
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single new grad that i work with
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typically wants to do some sort of labs
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like i think they're really worried
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about
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someone coming in with acute diarrhea
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should i do a basic metabolic panel
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i'm really worried that they're going to
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be dehydrated and it's really hard to
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trust that and trust your own clinical
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judgment when you're a brand new grad
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or you're a newer clinician but for the
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most part if they don't have underlying
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conditions if on your physical
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assessment they don't have any signs of
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either orthostasis
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or dry mucous membranes etc etc volume
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depletion
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typically they as long as they're taking
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adequate hydration and you
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advise them of the care and the alarm
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signs and symptoms they don't
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necessarily need labs
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for the patients who are higher risk
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that i mentioned
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you want to potentially consider doing
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stool stool cultures
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as well as um potentially a cbc
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um although if you do a differential it
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won't it doesn't in this scenario of
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diarrhea doesn't necessarily reliably
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tell you on the differential if it's
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parasitic versus viral versus bacterial
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et cetera et cetera
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but it may be more significant in the
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more significant
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serious in illnesses you will see some
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changes in the cbc with diff
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that's what i understand at least so a
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basic metabolic panel is definitely
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um appropriate if somebody looks volume
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depleted a cbc with differential
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if they have a more severe presentation
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stool cultures and high risk patients or
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specific scenarios especially if they
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have signs of inflammatory
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um diarrhea so again fever blood and
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stool mucous and stool
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so that's like the general overview of
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diarrhea and i don't really have a
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comprehensive list of red flag diagnoses
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so in next week's video i'm going to be
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talking about the
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breakdown of ideologies as it relates to
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the micro
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like the microbiology and like the
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testing a little bit more
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as well as those red flag diagnoses but
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i just encourage you to just be really
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careful when it comes to diarrhea
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making sure that you're not missing
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anything
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um when it comes to a red flag and i
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don't necessarily have a like a
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comprehensive differential diagnosis
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list of diarrhea
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red flags but just know that and i'll
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talk more about it in in next week's
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video in terms of the
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breakdown of the more severe underlying
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pathogens but when it comes to anybody
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with abdominal pain just treading very
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cautiously
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and expanding your differential
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diagnosis list to include the red flags
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of abdominal pain as well so
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uh so that's it for this video if you
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[Music]
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soon
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