A 5-year-old girl is brought to the clinic due to abdominal cramping and diarrhea. The diarrhea started 3 days ago and was initially watery but now contains visible mucus. The patient attends a small day care where several other children have recently developed similar diarrhea. Temperature is 38.3 C (101 F), blood pressure is 100/62 mm Hg, and pulse is 98/min. On examination, she appears uncomfortable but is appropriately answering questions and is interactive. The mouth is slightly dry. Heart and lung examinations are normal. The abdomen is diffusely tender to palpation without hepatosplenomegaly. A stool sample is positive for occult blood, and a stool culture is also obtained. The patient tolerates fluids she receives in the office. In addition to encouraging increased fluid intake, which of the following is the most appropriate management of this patient?

Question

A 5-year-old girl is brought to the clinic due to abdominal cramping and diarrhea.  The diarrhea started 3 days ago and was initially watery but now contains visible mucus.  The patient attends a small day care where several other children have recently developed similar diarrhea.  Temperature is 38.3 C (101 F), blood pressure is 100/62 mm Hg, and pulse is 98/min.  On examination, she appears uncomfortable but is appropriately answering questions and is interactive.  The mouth is slightly dry.  Heart and lung examinations are normal.  The abdomen is diffusely tender to palpation without hepatosplenomegaly.  A stool sample is positive for occult blood, and a stool culture is also obtained.  The patient tolerates fluids she receives in the office.  In addition to encouraging increased fluid intake, which of the following is the most appropriate management of this patient?

Quizplus · Accepted Answer

11ec25c8_d6b2_c6dd_bc81_81322560cafc_MD0003_00 This patient with fever, abdominal cramping, and diarrhea has acute gastroenteritis. Although acute gastroenteritis is most commonly caused by viruses, bacterial infection (eg, Salmonella, Escherichia coli) should be suspected when the stool contains mucus and blood. Stool culture is diagnostic of bacterial gastroenteritis. Well-appearing children with acute diarrhea (as in this case) are treated with supportive care (eg, oral rehydration, antipyretics) and close follow-up only. Antibiotics are not recommended for mild disease (eg, mild dehydration, normal mentation) because their benefit is limited, and antibiotic resistance can occur with unnecessary use (Choice C). In addition, empiric antibiotics increase the risk of life-threatening hemolytic uremic syndrome in patients with bloody diarrhea due to Escherichia coli O157:H7. Patients who are severely ill (eg, extraintestinal disease, worsening/prolonged symptoms, hospitalized) with bacterial gastroenteritis may require antibiotic therapy based on the results of the stool culture. For example, antibiotics may shorten the duration of illness in patients hospitalized for severe Salmonella gastroenteritis that causes high fever and profuse diarrhea. (Choices A and B) Abdominal ultrasound and air contrast enema are used to diagnose and treat intussusception, which presents in young children (age 6 months to 3 years) with episodic abdominal pain and bloody ("currant jelly") stools. In contrast to this patient's persistent cramping and diffuse tenderness, children with intussusception typically have no or only focal abdominal tenderness between painful episodes. In addition, this patient's history of sick contacts makes an infectious cause more likely. (Choice D) Bismuth subsalicylate is not generally recommended in children due to limited benefit and the risk of Reye syndrome and salicylate toxicity. (Choice F) Loperamide is an antimotility drug not recommended in children due to its potential side effects, including paralytic ileus, toxic megacolon, and CNS depression. Also, decreased intestinal motility can prolong fecal shedding of some bacterial diarrheas (eg, Shigella, E coli). Educational objective: Bacterial gastroenteritis should be suspected in a patient with fever, abdominal cramping, and bloody or mucoid diarrhea. Positive stool culture is diagnostic, and treatment is generally supportive care and close follow-up in well-appearing children. Empiric antibiotics are not recommended due to the increased risk of hemolytic uremic syndrome associated with Escherichia coli O157:H7. References: Acute diarrhea in children. (http://www.ncbi.nlm.nih.gov/pubmed/26946776)

A 5-Year-Old Girl Is Brought to the Clinic Due to Abdominal