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Old 07-13-2011
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Question Watery Diarrhea - What is the Best Initial Treatment

A fourth-year medical student is working in a medical relief group in Haiti for several months. Several parents bring their children to the clinic and explain that the children have had profuse, watery stool along with watery vomiting. All of the children are afebrile, slightly hypotensive, and tachycardic but have a normal respiratory rate. Urine output is reduced.

What would be the best immediate management of this diarrhea?

a) Antibiotics
b) Diphenoxylate
c) IV Normal Saline + Dextrose 5%
d) Loperamide
e) Oral Dehydration Solutions
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E) Oral Dehydration solutions.

Sounds a little like this question - http://www.usmle-forums.com/usmle-st...-diarrhea.html
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I'd say if the people are hypotensive give them IV NS + 5% Dextrose slowly over 12 hrs..
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Quote:
Originally Posted by rulz View Post
A fourth-year medical student is working in a medical relief group in Haiti for several months. Several parents bring their children to the clinic and explain that the children have had profuse, watery stool along with watery vomiting. All of the children are afebrile, slightly hypotensive, and tachycardic but have a normal respiratory rate. Urine output is reduced.

What would be the best immediate management of this diarrhea?

a) Antibiotics
b) Diphenoxylate
c) IV Normal Saline + Dextrose 5%
d) Loperamide
e) Oral Dehydration Solutions
these ve to b oral rehydration solutions
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Quote:
Originally Posted by rulz View Post
A fourth-year medical student is working in a medical relief group in Haiti for several months. Several parents bring their children to the clinic and explain that the children have had profuse, watery stool along with watery vomiting. All of the children are afebrile, slightly hypotensive, and tachycardic but have a normal respiratory rate. Urine output is reduced.

What would be the best immediate management of this diarrhea?

a) Antibiotics
b) Diphenoxylate
c) IV Normal Saline + Dextrose 5%
d) Loperamide
e) Oral Dehydration Solutions
I think the answer is Oral solutions...
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Old 07-13-2011
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i would choose e) to treat dehydrations first but what is this cause? vibrio? ETEC? both are possible, right?
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oral rehydration solution
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Correct Answer Correct answer is E.

Correct answer is E.

This patient has V. Cholera infection. First INITIAL treatment for the patient with V. Cholera with mild to moderate diarrhea and dehydration is Oral Fluid. The IV Saline + Dextrose 5% its a Maintenance Dose after the patient is not longer hypotensive.

Regarding Option C) It could be considerate a treatment if it were only normal saline for Severe dehydration, but dextrose with normal saline its considered a maintenance dose. For Cases as midly to moderate it unlikely to give this to prevent electrolyte imbalances such hypernatremia.

This is a Quote from emedicine:
eMedicine Link

"The goal of the rehydration phase is to restore normal hydration status, which should take no more than 4 hours. Set the rate of infusion in severely dehydrated patients at 50-100 mL/kg/h. Lactated Ringer solution is preferred over isotonic sodium chloride solution because saline does not correct metabolic acidosis."

"Only use the intravenous route (1) during the rehydration phase for severely dehydrated patients for whom an infusion rate of 50-100 mL/kg/h is advised, (2) for moderately dehydrated patients who do not tolerate the oral route, and (3) during the maintenance phase in patients considered high stool purgers (ie, >10 mL/kg/h)."
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if pt has vomiting so how he can benefit oral hydration?
and is this step 1 question?
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Old 07-13-2011
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"Best initial treatment" questions are usually step 2 questions - where is this from, if you don't mind - thanks for posting though.
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Quote:
Originally Posted by dr_lizard View Post
if pt has vomiting so how he can benefit oral hydration?
and is this step 1 question?
In fact i found it like step 2 question but it appear on a question bank for step 1 to me this morning. But ive seen a similar on qbank kaplan. So today on usmle Rx also.

On the options given that was the more accurate.
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Quote:
Originally Posted by ashishkabir View Post
"Best initial treatment" questions are usually step 2 questions - where is this from, if you don't mind - thanks for posting though.
You welcome, Usmle Rx qbank for step 1 sir.
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Old 07-14-2011
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thanks for the question, even though it's a bit confusing you'd think vomiting means they don't tolerate oral route so IV would be preferable.
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the kid is vomiting wont he through out the ORS too?

I am with option C
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Quote:
Originally Posted by Hope2Pass View Post
E) Oral Dehydration solutions.

Sounds a little like this question - http://www.usmle-forums.com/usmle-st...-diarrhea.html
but the patient is vomiting, so IVF should be given
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Quote:
Originally Posted by rulz View Post
Correct answer is E.

This patient has V. Cholera infection. First INITIAL treatment for the patient with V. Cholera with mild to moderate diarrhea and dehydration is Oral Fluid. The IV Saline + Dextrose 5% its a Maintenance Dose after the patient is not longer hypotensive.

Regarding Option C) It could be considerate a treatment if it were only normal saline for Severe dehydration, but dextrose with normal saline its considered a maintenance dose. For Cases as midly to moderate it unlikely to give this to prevent electrolyte imbalances such hypernatremia.

This is a Quote from emedicine:
eMedicine Link

"The goal of the rehydration phase is to restore normal hydration status, which should take no more than 4 hours. Set the rate of infusion in severely dehydrated patients at 50-100 mL/kg/h. Lactated Ringer solution is preferred over isotonic sodium chloride solution because saline does not correct metabolic acidosis."

"Only use the intravenous route (1) during the rehydration phase for severely dehydrated patients for whom an infusion rate of 50-100 mL/kg/h is advised, (2) for moderately dehydrated patients who do not tolerate the oral route, and (3) during the maintenance phase in patients considered high stool purgers (ie, >10 mL/kg/h)."

The patient is hypotensive and tachycardic, meaning they need reperfusion. NSS will do. and CHOLERA will specifically say RICE WATERY stool.
This may be due to other bacteria that causes WATERY DRH, but the question stem does not ask for the source. Just focus on what Tx would you initially give a patient who is Tachycardic and hypotensive from DRH - this is apparent that Dehaydration is causing perfusion problems, fastest way to reperfuse is thru IV, not oral.
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Old 07-14-2011
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Quote:
Originally Posted by rulz View Post
A fourth-year medical student is working in a medical relief group in Haiti for several months. Several parents bring their children to the clinic and explain that the children have had profuse, watery stool along with watery vomiting. All of the children are afebrile, slightly hypotensive, and tachycardic but have a normal respiratory rate. Urine output is reduced.

What would be the best immediate management of this diarrhea?

a) Antibiotics
b) Diphenoxylate
c) IV Normal Saline + Dextrose 5%
d) Loperamide
e) Oral Dehydration Solutions
Dehydration is the opposite of rehydration, if you gave them dehydration solutions you would make them worse. Answer should be oral rehydration solution.

If someone comes in dehydrated, whether from vomitting, diarrhea, stuck in the desert, diabetic ketoacidosis with polyuria, etc, first step in management is always rehydration. Most times you either give 0.9% saline or 0.9% saline with dextrose. If cholera or other secretory diarrhea, use oral rehydration solution, which is a formulation designed by the WHO specifically for this purpose and has been shown to be the single most important life-saving treatment for cholera.
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Quote:
Originally Posted by heights View Post
Dehydration is the opposite of rehydration, if you gave them dehydration solutions you would make them worse. Answer should be oral rehydration solution.

If someone comes in dehydrated, whether from vomitting, diarrhea, stuck in the desert, diabetic ketoacidosis with polyuria, etc, first step in management is always rehydration. Most times you either give 0.9% saline or 0.9% saline with dextrose. If cholera or other secretory diarrhea, use oral rehydration solution, which is a formulation designed by the WHO specifically for this purpose and has been shown to be the single most important life-saving treatment for cholera.
Great answer... and great observation... my bad, didnt notice at first.. i just miss typed:sorry: ... but after i realize the forum wont let me change, only admins can... But as you said, Answer is E and its Oral Hydration Solution.
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The patient is hypotensive and tachycardic, meaning they need reperfusion. NSS will do. and CHOLERA will specifically say RICE WATERY stool.
This may be due to other bacteria that causes WATERY DRH, but the question stem does not ask for the source. Just focus on what Tx would you initially give a patient who is Tachycardic and hypotensive from DRH - this is apparent that Dehaydration is causing perfusion problems, fastest way to reperfuse is thru IV, not oral.
Careful there, not once have I seen an NBME question say "rice water stool". From what I've heard they try as much as possible not to use buzz words or phrases like that. The rest of the stem screams cholera...Haiti just had a huge outbreak of cholera since the earthquake, multiple people are infected, feco-oral transmission so kids are more likely to be infected, vomitting, secretory diarrhea, etc. Other causes of watery diarrhea, such as ETEC, are much less likely in this scenario.

Ps...Great question rulz! These type of questions may be more common on step 2, but I got a similar question on the Free 150.

Last edited by heights; 07-15-2011 at 12:03 PM. Reason: added ps.
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Old 07-15-2011
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Quote:
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Careful there, not once have I seen an NBME question say "rice water stool". From what I've heard they try as much as possible not to use buzz words or phrases like that. The rest of the stem screams cholera...Haiti just had a huge outbreak of cholera since the earthquake, multiple people are infected, feco-oral transmission so kids are more likely to be infected, vomitting, secretory diarrhea, etc. Other causes of watery diarrhea, such as ETEC, are much less likely in this scenario.

Ps...Great question rulz! These type of questions may be more common on step 2, but the free 150 for Step 1 that I did yesterday had a question on a guy stuck in desert and what was the best initial treatment. Ans: 0.9% saline.
Thanks for spoiling one of the q's from free 150
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Thanks for spoiling one of the q's from free 150
Height!!!!! dont do that hahahahaha... remember that a few of us really need to "DONT KNOW" the question from 150 because we may take it later
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Old 07-15-2011
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Height!!!!! dont do that hahahahaha... remember that a few of us really need to "DONT KNOW" the question from 150 because we may take it later
Oops, sorry guys! Didn't mean to do that, but look at it this way- if you still remember it by the time you do your 150, you'll also remember it when you take your exam
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