Date:
Patient:
MRN:
Clinician: (Emergency Physician, Urgent Care Physician, Primary Care Physician)
Reason for Visit:
Evaluation of symptoms suggestive of foodborne illness (nausea, vomiting, diarrhea, abdominal cramps, fever)
Assessment of dehydration status
Diagnostic testing (if indicated)
History of Present Illness:
Onset and duration of symptoms
Severity and character of symptoms (e.g., watery diarrhea vs. bloody diarrhea)
Presence of associated symptoms (fever, chills, headache, muscle aches)
Recent travel history (potential exposure to contaminated food or water)
Suspected source of illness (contaminated food or beverage)
Past Medical History:
Underlying medical conditions that may increase susceptibility (immunodeficiency, inflammatory bowel disease)
Recent surgeries or procedures (increased risk of hospital-acquired infections)
Social History:
Recent dietary habits (consumption of potentially high-risk foods)
Recent gatherings or events where contaminated food may have been served
Physical Exam:
Vital Signs:
Assess for fever, tachycardia (rapid heart rate) suggestive of infection.
Monitor for signs of dehydration (orthostatic hypotension – low blood pressure upon standing, dry mucous membranes).
Abdominal: Tenderness, distention, or guarding (increased muscle tone) upon palpation.
Labs (may not be necessary in all cases):
Stool cultures: Identify the specific organism causing the illness (e.g., Salmonella, E. coli, Campylobacter) – may take several days for results.
Complete Blood Count (CBC) with differential: Elevated white blood cells may suggest infection.
Basic Metabolic Panel (BMP): Evaluate for electrolyte imbalances due to dehydration.
Consider mentioning other labs ordered based on suspicion:
Clostridium difficile (C. Diff) toxin testing (common cause of hospital-acquired diarrhea)
Imaging (not routinely used):
Abdominal imaging (ultrasound, X-ray) may be used in some cases to rule out other causes of abdominal pain (appendicitis, bowel obstruction).
Assessment:
Based on the clinical presentation, consider the following diagnoses:
Bacterial gastroenteritis (most common)
Viral gastroenteritis (rotavirus, norovirus)
Parasitic infection (less common)
Identify the potential source of contamination based on history and travel information (if available).
Assess the severity of illness and dehydration status.
Plan:
Outline the treatment plan based on the assessment:
Supportive care: Oral or intravenous rehydration to correct fluid and electrolyte imbalances.
Antidiarrheal medications: Loperamide (for non-bloody diarrhea) may help manage symptoms but should not be used if fever or blood is present.
Antibiotics: Not routinely used for most foodborne illnesses. May be considered in specific cases based on the identified organism and severity of illness.
Dietary modifications: Recommend a bland diet (BRAT diet – bananas, rice, applesauce, toast) for initial symptom management, followed by gradual reintroduction of other foods.
Prognosis:
Briefly discuss the prognosis. Most foodborne illnesses are self-limited and resolve within a few days with supportive care.
Advise on the expected duration of symptoms and potential complications (dehydration).
Education:
Document any education provided to the patient regarding:
The importance of proper hand hygiene to prevent the spread of infection
Safe food handling practices to prevent future illness
Signs and symptoms of dehydration and when to seek further medical attention
Dietary recommendations for symptom management and recovery
Notes:
Include any additional relevant information not covered above, such as the patient’s ability to tolerate oral fluids, and any concerns they may have.
Consider reporting suspected foodborne illness outbreaks to local health authorities to help identify and prevent further cases.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. It is important to consult with a healthcare professional for diagnosis, treatment recommendations, and follow-up care.