CHART NOTE
A 23-year-old gentleman in good health until 4 to 5 days ago, when he developed acute-onset high fever, abdominal cramping, nausea, and profuse watery diarrhea. Temperature was up to 102 at home. The patient has continued to work despite feeling ill but today became faint.
On examination, he is a pleasant young man who is in no acute distress. Blood pressure is 98/64. HEENT clear. Chest clear. Cardiac examination reveals regular rate and rhythm at about 100. Abdomen soft, diffusely tender to palpation.
ASSESSMENT
Acute viral gastroenteritis with probable dehydration.
Given the severity of his symptoms, I am going to go ahead and treat expectantly with antibiotics, obtain a stool culture as well as Gram stain, begin on Bactrim DS, Phenergan for nausea, Donnatal for abdominal cramping. Patient should definitely rest at home for next several days. To follow first clear liquid, then BRAT diet. Return to clinic p.r.n.
FOOTNOTE
Line 7. Alternative: 4-5.
Line 26. BRAT (bananas, rice, applesauce, toast).
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