A previously healthy 45-year-old woman presents with 8 days of watery diarrhea, associated with abdominal cramping and nausea, following a 2-week trip to Lagos, Nigeria. She has approximately 6 to 8 stools per day. She denies fever, chills, vomiting, hematochezia, or systemic symptoms. Diarrhea began shortly after returning home. She admits to eating food at a roadside stand but did not drink tap water during travel. She has no systemic toxicity and is hemodynamically stable.
On urgent care arrival, the patient appears weak, fatigued, and in mild discomfort. On physical examination, she does not have fever, chills, or weight loss. Palpation of her abdomen yields soft, mild, and diffuse tenderness without rebound or guarding. Her past medical history, medication list, and review of systems are unremarkable. Initial evaluation of a stool sample is negative, and CBC and BMP are normal.
What is the best next step in management of this patient?
- Refer the patient to the emergency department for IV fluids, antiemetics, and empiric antimicrobials.
- Discharge the patient home and ask her to provide 2 more stool samples over the course of the next 7 days.
- Inform the patient that she needs more testing by an infectious disease specialist.
- Prescribe electrolyte fluids, loperamide, and 1000 mg PO azithromycin, followed by 500 mg PO daily until symptoms are resolved as supportive treatment.
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Correct Answer: d. Prescribe electrolyte fluids, loperamide, and 1000 mg PO azithromycin, followed by 500 mg PO daily, until symptoms are resolved as supportive treatment.
This patient’s initial ova and parasite examination was negative, lowering your suspicion for protozoan sources (eg, Giargia or Entamoeba histolytica); however, 3 separate stool ova and parasite samples would be ideal. You determined that her travelers’ diarrhea was most likely bacterial in origin since she did not have bloody stools or systemic involvement. Empiric antibiotic treatment was prescribed due to the severity of symptoms, but after discussion she declined due to concern about secondary yeast infection. Instead, she was recommended supportive therapy with bismuth subsalicylate. She used this for 3 days with complete resolution of symptoms.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
