A 34-year-old man presents to urgent care with complaints of intermittent abdominal cramping, bloating, and loose stools for the past 2 weeks. He denies fever, vomiting, or blood in the stool. He reports some fatigue and unintentional weight loss of approximately 4 lbs. His past medical history is unremarkable, and his immunizations are up to date.
His vital signs are heart rate, 88 beats/min; blood pressure, 120/72 mm Hg; respiratory rate, 16 breaths/min; and SpO2, 99% on room air. On physical examination, he is alert, with a soft, mildly tender abdomen in the periumbilical area with no rebounding or guarding, and he has no rash or edema. He has not sought prior care, as he thought the loperamide and calcium carbonate he took would help.
Part I: What would be the best next step in the clinical evaluation of this patient?
- Inquire further about timing of symptom onset and any recent travel, including the purpose of his travel, activities, exposures (food/drink, animals, insects, bodies of water), and possible ill travel companions.
- Determine that he has an acute case of gastroenteritis and treat symptomatically with supportive care.
- Discharge the patient, telling him that what he has is self-limited and will get better in a few days.
- Refer him to the emergency department for additional testing and evaluation.
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Correct Answer: a. Inquire further about timing of symptom onset and any recent travel, including the purpose of his travel, activities, exposures (food/drink, animals, insects, bodies of water), and possible ill travel companions.
When he tells you that he recently returned from a 3-week trip to rural Thailand, where he frequently ate street food and occasionally walked barefoot on soil, you order a stool ova and parasite examination and antigen tests because they are available in your clinic. You also obtain a CBC to evaluate for eosinophilia and anemia. Given his recent travel to Southeast Asia, you have suspicion for a geohelminth infection (eg, Ascaris lumbricoides, Ancylostoma duodenale, Necator americanus, Trichuris trichiura) or a bacterial infection (Giardia, Entamoeba histolytica). Other conditions on the differential include irritable bowel syndrome or early inflammatory bowel disease.
Part II: Which finding would most strongly suggest a geohelminth infection in this patient?
- Positive stool culture for Salmonella
- Eosinophilia on CBC
- Colonoscopy showing ulcerations
- Normal stool ova and parasite examination
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Correct Answer: b. Eosinophilia on CBC
Eosinophilia is a common finding in tissue-migrating helminth infections.
Case conclusion: Given the stability and absence of alarming features (eg, gastrointestinal bleeding, severe dehydration, or peritonitis), you determined that this patient was safe for outpatient management. You discharged him home with a pre-emptive prescription of albendazole 400 mg PO for 1 dose, along with instructions for hydration and dietary adjustments. You strongly advised that he follow up with his primary care provider for additional stool testing and advised him to return for worsening pain, fever, bloody diarrhea, or lack of improvement.
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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.
