Diarrhea

When we think of Diarrhea, we usually think of at least 4 watery stools per day. Some people are a little obsessive about their bowel movements, think that they always have to be well-formed, and get shaken if stools become loose. One or two loose stools a day can happen to anyone, and does not constitute disease.

Also, if there’s a watery stool, and another one within 5 minutes, that’s just because the rectum hadn’t quite finished. It only counts as one episode.

For the clinicianโ€™s condensed thought-process when face-to-face with a patient, select below. Those summaries will have links to more in-depth texts on the topic.

Acute Diarrhea (going on under 2-3 weeks)

Chronic Diarrhea (lasting 3-4 weeks and more)

Shortness of Breath (SOB)

NOTE — Don’t get thrown by the abbreviation “SOB.” It’s universally standard in medical charting (likely one reason we don’t want patients to read their charts on their own). Select from below:

Life-Threatening SOB (we always do a rapid assessment)

Acute SOB (lasting 1 – 2 weeks, maybe 3 – 4 weeks at the most)

Chronic SOB (maybe a few weeks, could be months or more)

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Joint Pain — Arthritis

Arthritis is when joints are painful, red, hot, swollen. Arthralgia means that joints simply hurt. The same diseases can cause both. But often “joint” pains may not involve joints at all, but be due to tendons, ligaments, bursa, bones, or muscles. That’s a different topic (Musculoskeletal Conditions).

Some diseases affect many joints, usually small ones like wrists, hands, fingers; ankles, feet, toes. This gets called Polyarticular (“articular” = “joint”). Others affect only one joint (Monoarticular), or a just few (Oligoarticular). These are usually the larger joints, like shoulder, elbow, maybe wrist; hip, knee, maybe ankle.

Select a topic on diagnosing Joint Diseases (arthritis / arthralgias):

Many Joints (Polyarticular)

Few Joints / Just One Joint (Oligoarticular / Monoarticular)

yalemedicine.org ………………………………………………………………………………………………………… medicalnewstoday.com

Cough

Cough is always due to a Respiratory Tract condition, somewhere between the nose & depths of the lung.

We divide it into โ€œUpperโ€ and โ€œLowerโ€ Respiratory Tracts:
โ€ข Upper Tract: nose, sinuses, throat, & trachea (windpipe)
โ€ข Lower Tract: lungs
โ€ข See Diagrams — Upper and Lower Respiratory Systems

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For the clinician’s approach to diagnosing “Cough,” select either:

Acute Cough (lasting 2-3 weeks or less)

Chronic Cough (going on 4 weeks or more)

Acute Cough

An Acute Cough is one which has been going on less than 2-3 weeks.

Anyone with “acute cough” may not be allowed inside a building without a Covid Test. But some patients need to be seen no matter what; every office or clinic has its own mechanism, maybe in a designated exam room, maybe sending them to an Urgent Care or E.R.  These are patients who, in addition to a cough, also have:

Causes of Acute Cough

zzzUpper Respiratory Tract ConditionszzzLower Respiratory Tract Conditions
โ€ข Common Cold
โ€ข Allergic Rhinitis (Hay Fever; “Allergies”)
โ€ข Sinusitis
โ€ข Tracheitis (โ€œCroupโ€ in children under 3)
โ€ข Hypertension Medication (โ€œACE-Inhibitorsโ€)
โ€ข (if sudden onset while eating: Aspiration)
xxx
xxx
โ€ข Covid-19
โ€ข Influenza (& other viruses)
โ€ข Pneumonia (both common germs & rare)
โ€ข Asthma
โ€ข COPD (exacerbation)
โ€ข Acute Bronchitis
โ€ข Heart Failure
โ€ข Pertussis (โ€œwhooping coughโ€)  

For Anatomy, see: Diagram — Upper Respiratory Tract and Diagram — Lower Respiratory Tract. See also Acute Cough — Full Text for an in-depth discussion.

STEP #1  —  Is this Covid?  If going on under 2 wks, assume yes.  Get a Covid Test.

  • Test Positive ย โ†’ diagnosis made; itโ€™s Covid-19
  • Test Negative ย โ†’ย  Might still be, but go to Step #2.ย  May repeat test in 2-3 days; if still Negative, ย  most likely itโ€™s NOT Covid.
  • Results still pending ย โ†’ย  Isolate just in case.ย  If Dec.- April, and suspect Influenza (abrupt onset, fever, muscles aches, and going on less than 3-4 days). Test or just treat for Influenza

STEP #2ย  —ย  If not Covid, or test results pending, is the illness causing COUGH from
…..โ€ข Upper Respiratory Tract (from nose, sinuses, throat); or
…..โ€ข Lower Respiratory Tract (from the lungs); or
…..โ€ข We Canโ€™t Tell ?

Upper Respiratory:  Significant nasal symptoms (runny nose / sneezing / congestion); AND

  —  No Fever, No SOB, Normal Lung Exam (by stethoscope)

  • a mild fever is possible at beginning, goes away soon
  • fever can occasionally occur with Sinusitis

Lower Respiratory:  Any of the following

  • Fever, especially if also muscle aches
  • SOB [always a dangerous symptom, if it’s “true” SOB]
  • Abnormal Lung Exam (by stethoscope)

Canโ€™t Tell:  Just a โ€œCoughโ€

  • No nasal symptoms, No fever, No SOB
  • Normal Lung Exam (by stethoscope)

If We Think LOWER RESPIRATORY cause of COUGH (Covid tests Negative twice)
These may be dangerous; if Covid negative twice, or pending, seek other cause.

Fever &/or Muscle Aches  โ†’  Itโ€™s likely Influenza (or another SIMPLE Virus)… UNLESS

  • Going on over 3-4 days without getting even the least bit better
  • Rales (crackles) on lung exam (suspect Pneumonia)
  • SOB (always makes condition potentially more serious — must check oxygen level)
    • Low oxygen or significant SOB, we often send to E.R. for X-ray and immediate labs
  • If any of above, we get a Chest X-ray (will diagnose Pneumonia)
    • Also suspect Pneumonia if: Cough + Fever + Pain with Deep Breath
  • Also X-ray if:  Elderly / chronically ill / immunocompromised
    • May send such patients with Cough + Fever to the ER

Bronchospasm by Lung Exam (wheezes, rhonchi, OR prolonged expiration โ†’  Diagnose:

**ย  Viral Bronchitis (if first episode)

**ย  Asthma (if previous episodes)

**ย  Chronic Bronchitis (if smoker with history of COPD)

**ย  Heart Failure (bronchospasm is rare; consider it only if other factors too, see right below)

Shortness of Breath (SOB) —  (and No Fever, No Bronchospasm) [click to explain โ€œtrueโ€ SOB]

**ย  Asthma / Chronic Bronchitis : most likely, if otherwise healthy

  • Treat on-site.ย  If symptoms improveย  โ†’ Diagnosis made.

**ย  Heart Failure —ย  possible as cause of cough, especially if any of following:

  • Older age, or Risks for Heart Disease
  • SOBย when lying flat in bed, needs to sit up (this often happens with asthma too)
  • Findingsย on Exam: swollen feet, “rales” in both lungs (wheezes possible, very unusual)

For SOB not improved with asthma treatment, may need to send to ER, esp. if low oxygen

NOTE  —  if patient’s cough is minimal, & SOB is the more prominent symptom, itโ€™s a different thought process for diagnosis (see topic Shortness of Breath).

If We Think UPPER RESPIRATORY cause of COUGH

** Allergic Rhinitis:ย  any of the following:

  • Lots of sneezing
  • Similarย episodes in the past, especially if lasted over a month
  • Findingsย on exam (pale, boggy mucus membranes inside nose; darkened lower eyelids; horizontal crease across tip of nose on top)

**ย  Sinusitis (bacteria):

  • Facialย pressure / constant green mucus (esp. if only one side of face)
  • Tapย on upper teeth on one side makes the cheek hurt
  • Maybe a fever
  • Mainย Way to Diagnose Sinusitis — โ€œcommon cold,โ€ going on for a week, suddenly got a lot worse

**  Common Cold:   Neither of the above scenarios. Common Cold is always the most likely diagnosis for an acute cough

If We Canโ€™t Tell if it’s UPPER or LOWER RESPIRATORY
No Nasal symptoms, No fever, No SOB, Normal lung exam

** Tracheitis  —  Most likely diagnosis

** Pertussisย  —ย  Might be, if any of the following:

  • Vomit after coughing fits
  • Notย even starting to get better after 2 weeks
  • Contactย with unvaccinated infant makes possible-Pertussis risky enough to treat

** Asthmaย  —ย  Still a possibility (even though Lung Exam sounds normal)

  • Veryย likely if person already had similar episodes in past, or has been diagnosed already
  • Might diagnose new Asthma if no improvement in 2 weeks (too long for Tracheitis)
  • No danger waiting, as long as there’s no SOB
  • Can always treat with asthma medications (inhalers) anyway

EXTRA  —  Sudden Onset Coughing (Choking) While Eating

** Foreign Body Aspiration

  • Only perform a Heimlich if person can’t make a single sound
  • NEVER do a Heimlich on someone who’sย actively coughing
  • Call 911, best from a landline
  • Ifย it’s you, & you’re alone, open the door & stumble outside (see Calling 911)

See Acute Cough โ€” Full Text for more in-depth explanations and discussions.

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