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Acute Gastroenteritis (GE) — Management

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1. Initial Assessment

History

• Duration of symptoms (diarrhea >14 days = persistent/chronic, not acute)
• Stool character: watery vs. bloody, volume per episode
• Associated symptoms: vomiting, fever, abdominal pain, tenesmus
• Exposure history: foreign travel, raw seafood, undercooked meat, camping/untreated water, recent antibiotics, daycare, outbreaks

Bloody diarrhea + fever + tenesmus → dysentery pattern → suggests invasive organisms (Campylobacter, Shigella) Large volume watery diarrhea → small bowel involvement (viral, cholera) Vomiting predominating, little diarrhea → norovirus or preformed toxin (Staph aureus)

Physical Examination

• Hydration status: dry mucous membranes, decreased skin turgor, sunken eyes (especially in children), reduced urine output
• Vital signs: hypotension + tachycardia → significant dehydration; fever + altered mental status → possible sepsis
• Abdominal exam: hyperactive bowel sounds are typical; focal tenderness, rebound, guarding, distension or rigidity → suspect surgical cause

Differential Diagnoses to Exclude

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2. Severity / Dehydration Assessment

• Score 0 = no dehydration
• Score 1–4 = some dehydration
• Score ≥5 = moderate–severe dehydration

• Mild (<5% body weight loss): thirsty, normal exam
• Moderate (5–10%): tachycardia, dry mucosae, decreased skin turgor
• Severe (>10%): hypotension, altered mental status, markedly decreased urine output, shock

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3. Investigations

Note: WBC and CRP are NOT reliable to distinguish viral vs. bacterial gastroenteritis. Stool cultures have a low yield in mild, uncomplicated cases.

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4. Rehydration — The Cornerstone of Treatment

Oral Rehydration Therapy (ORT) — First-line for mild–moderate dehydration

In children with mild gastroenteritis and minimal dehydration, dilute apple juice followed by preferred fluids is an acceptable alternative and results in fewer treatment failures than standard ORS.

• Mild dehydration: 50 mL/kg ORS over 4 hours
• Moderate dehydration: 100 mL/kg ORS over 4 hours
• Supplement with 10 mL/kg per liquid stool and 2 mL/kg per vomiting episode
• Give small, frequent sips if vomiting is present

IV Rehydration — for moderate–severe dehydration or ORT failure

• Normal saline (0.9% NaCl) or Lactated Ringer's bolus 20 mL/kg IV, repeat as needed
• Transition to oral rehydration as soon as tolerated
• Reassess hydration status after each bolus

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5. Antiemetics

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6. Antidiarrheals

Do not use antidiarrheals in dysenteric illness (bloody diarrhea, high fever) — risk of toxic megacolon, worsened HUS.

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7. Antibiotics

• Severe dysenteric illness (high fever, bloody diarrhea)
• Immunocompromised patient
• Traveler's diarrhea (moderate–severe)
• Suspected cholera

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8. Diet and Feeding

• Early refeeding is encouraged once rehydration is underway — fasting worsens bowel absorptive capacity
• Resume age-appropriate diet as soon as tolerated
• In children, breastfeeding should continue throughout illness
• Avoid: sugary drinks, apple juice (full strength), carbonated beverages (hyperosmolar — worsen diarrhea)
• Lactose restriction is generally not necessary unless clear lactose intolerance

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9. Zinc Supplementation (Children)

• WHO recommends zinc 10–20 mg/day × 10–14 days in children <5 years in developing settings
• Reduces severity and duration of diarrhea, decreases risk of future episodes

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10. Probiotics

• Some evidence for Lactobacillus rhamnosus GG and Saccharomyces boulardii reducing duration of diarrhea by ~1 day in children
• Not universally recommended in all guidelines but reasonable adjunct

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11. Disposition

• No improvement in 48 hours
• Worsening symptoms, inability to keep fluids down
• Bloody stools, high fever
• Signs of worsening dehydration (markedly reduced urine output, extreme lethargy)

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Key Pathogens Summary

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• Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9th ed., Ch. 131
• Rosen's Emergency Medicine: Concepts and Clinical Practice, Ch. 80
• Yamada's Textbook of Gastroenterology, 7th ed., Ch. Syndromic Management of Gastroenteritis

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Cardiovascular System (CVS) Examination

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SEQUENCE OF EXAMINATION

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1. GENERAL INSPECTION

• Malar flush (mitral stenosis)
• Pallor (anaemia, low output states)
• Central cyanosis (check tongue and lips — congenital heart disease, Eisenmenger's)
• Peripheral cyanosis (fingers/toes — low output, cold)
• Marfan's syndrome (tall, arachnodactyly, high-arched palate — aortic root disease)
• Turner's syndrome (coarctation of aorta)
• Down's syndrome (ASD, VSD, AV canal defects)

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2. HANDS

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3. RADIAL PULSE

Rate

• Normal: 60–100 bpm
• Bradycardia <60, tachycardia >100

Rhythm

• Regular — sinus rhythm
• Irregularly irregular — atrial fibrillation
• Regularly irregular — ectopics, 2nd degree AV block

Character (best assessed at carotid)

Volume: Full, normal, or low (reduced → poor output, dehydration, AS)

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4. BLOOD PRESSURE

• Measure in both arms (difference >20 mmHg → aortic dissection, subclavian stenosis, coarctation)
• Pulse pressure = systolic − diastolic
  • Wide (>60 mmHg): AR, PDA, hyperthyroidism, anaemia, fever
  • Narrow (<25 mmHg): AS, cardiac tamponade, severe heart failure

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5. JUGULAR VENOUS PRESSURE (JVP)

Technique

• Patient at 30–45° with head slightly rotated to the left
• Use the internal jugular vein (preferred; not valved, directly in line with RA)
• Measure vertical height of pulsation above the sternal angle (angle of Louis)
• Normal: <4.5 cm above sternal angle at 45°
• Pulsations above the clavicle in the sitting position are clearly abnormal (clavicle-to-RA distance ≥10 cm)

JVP vs Carotid Pulse — How to Distinguish

The JVP Waveform

Abnormal JVP Waveforms

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6. FACE & NECK

• Eyes: corneal arcus (hypercholesterolaemia), xanthelasma (hyperlipidaemia), conjunctival pallor (anaemia)
• Mouth: central cyanosis (tongue), high-arched palate (Marfan's)
• Carotid pulse: character and volume (slow-rising = AS; collapsing = AR)
• Carotid bruits: auscultate over carotids (atherosclerosis, radiation of AS)

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7. PRECORDIUM

Inspection

• Chest shape: pectus excavatum, pectus carinatum, kyphoscoliosis (may displace heart, cause murmurs)
• Visible apex beat: normally in 5th ICS, mid-clavicular line
• Scars: midline sternotomy (CABG, valve replacement), left lateral thoracotomy (mitral valvotomy, PDA ligation), pacemaker/ICD pocket (left infraclavicular)
• Prominent pulsations: left parasternal heave, visible apex

Palpation

• Normally: 5th ICS, mid-clavicular line
• Assess: position, character, and area

• Sustained left parasternal lift → RV hypertrophy / dilatation (pulmonary hypertension, pulmonary stenosis, ASD)

• Systolic thrill at aortic area → AS
• Systolic thrill at LSE → VSD, HOCM
• Diastolic thrill at apex → MS

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8. AUSCULTATION

Technique

• Diaphragm: high-frequency sounds (S1, S2, AR murmur, pericardial rub)
• Bell: low-frequency sounds (S3, S4, MS rumble) — use with light pressure

Auscultatory Areas

• Left lateral decubitus position + bell at apex → best for MS rumble and S3/S4
• Sitting forward, expiration → best for AR early diastolic murmur
• Standing → suppresses most murmurs; HOCM louder, MVP click moves earlier
• Squatting → most murmurs louder; HOCM softer, MVP click moves later
• Valsalva → HOCM louder (decreased preload)

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Heart Sounds

S1 (Mitral + Tricuspid Closure)

S2 (Aortic + Pulmonary Closure)

• Physiological splitting of S2: heard in inspiration (A2 before P2); splitting widens in inspiration, narrows in expiration
• Wide fixed splitting: ASD (equalization of RA/LA pressures)
• Wide splitting with respiratory variation: RBBB, pulmonary stenosis (delayed P2), pulmonary hypertension with RV failure
• Reversed/paradoxical splitting: LBBB, AS, HOCM (delayed A2; splits on expiration, closes on inspiration)
• Loud A2: systemic hypertension
• Loud P2 (palpable): pulmonary hypertension
• Soft A2: severe AS

S3 (Ventricular Gallop)

• Low-pitched, heard at apex with bell, in early diastole (Ken-tuck-y)
• Physiological in children and young adults (<40 years)
• Pathological in adults → indicates LV failure, dilated cardiomyopathy, severe MR

S4 (Atrial Gallop)

• Low-pitched, heard just before S1 (Ten-nes-see)
• Due to atrial contraction into a stiff, non-compliant ventricle
• Causes: LVH (hypertension, AS, HOCM), acute MI, hypertrophic cardiomyopathy
• Never heard in AF (no atrial contraction)

Opening Snap (OS)

• High-pitched, early diastolic sound after S2
• Mitral stenosis (mobile, non-calcified valve)
• Short S2–OS interval → more severe MS (high LA pressure)

Ejection Click

• High-pitched early systolic click
• Aortic or pulmonary valve stenosis (bicuspid aortic valve, valvular PS)
• Pulmonary ejection click softens with inspiration (unique among right-sided sounds)

Mid-Systolic Click

• Mitral valve prolapse (MVP)
• Moves earlier with standing/Valsalva (reduced preload)
• Moves later with squatting/leg raising (increased preload)

Pericardial Friction Rub

• High-pitched, scratchy, three-component sound (systolic + early diastolic + presystolic)
• Heard best with patient sitting forward, in expiration
• Acute pericarditis, post-MI (Dressler's syndrome), uraemia

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Murmurs

Grading (Levine Scale)

Systolic Murmurs

Diastolic Murmurs (always pathological)

Continuous Murmurs

• PDA: continuous "machinery" murmur, upper LSE
• AV fistula, coarctation collaterals

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9. PERIPHERAL EXAMINATION

• Sacral oedema: pitting, in bedridden patients (right heart failure)
• Ankle/leg oedema: bilateral pitting → right heart failure, hypoalbuminaemia; unilateral → DVT, lymphoedema
• Hepatomegaly: tender, pulsatile in TR; congestive hepatomegaly in RHF
• Splenomegaly: infective endocarditis
• Ascites: severe right heart failure, constrictive pericarditis
• Lung bases: fine end-inspiratory crepitations → pulmonary oedema (LHF)

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10. CLOSING THE EXAMINATION

• Check temperature chart, urine output
• Review ECG, chest X-ray, echocardiogram
• Measure oxygen saturation
• Fundoscopy (hypertensive/diabetic changes, Roth spots in endocarditis)

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• Harrison's Principles of Internal Medicine, 22nd ed., Ch. 246 — Cardiovascular Examination
• Fuster & Hurst's The Heart, 15th ed. — Clinical Cardiovascular Examination
• Goldman-Cecil Medicine — Physical Examination for Detection of Cardiovascular Disease

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CVS Examination — Illustrated Guide

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1. GENERAL INSPECTION & HANDS

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2. PULSE — Rate, Rhythm, Character

Radio-radial delay (different pulses in each wrist) → coarctation of aorta / aortic dissection Radio-femoral delay → coarctation of aorta

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3. BLOOD PRESSURE

• Measure both arms — difference >20 mmHg → aortic dissection, subclavian stenosis
• Wide pulse pressure (>60 mmHg): AR, PDA, thyrotoxicosis, anaemia
• Narrow pulse pressure (<25 mmHg): severe AS, tamponade, heart failure

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4. JUGULAR VENOUS PRESSURE (JVP)

Technique — Patient positioning

• Normal: <4.5 cm above sternal angle at 45°
• Pulsation above the clavicle in sitting = always elevated (clavicle–RA distance ≥10 cm)
• Use internal jugular vein (preferred — not valved, directly communicates with RA)

The JVP Waveform

Abnormal JVP — Clinical Correlations

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5. PRECORDIUM

Auscultation Areas

Apex Beat Character

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6. HEART SOUNDS

S1 & S2 — Normal and Abnormal

S3 and S4

Use the bell with light pressure at the apex for S3 and S4. Position patient in left lateral decubitus.

Opening Snap, Clicks, Rub

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7. MURMURS

Radiation Patterns — AS and MR

Systolic Murmurs

Diastolic Murmurs (always pathological)

Dynamic Manoeuvres

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8. PERIPHERAL SIGNS (Complete the Exam)

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Summary — "What to Say at the End"

"To complete my examination I would like to:

• Check the blood pressure in both arms and lying/standing
• Review the ECG, chest X-ray, and echocardiogram
• Measure oxygen saturation
• Perform fundoscopy (HTN, diabetic, Roth spots)
• Check urine dipstick (haematuria in IE, proteinuria in HTN)"

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