Diarrhoea and Vomiting
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Assessment of Gastrointestinal Symptoms: Potential Dehydration
Patient Presentation
Introduction: Hi, I'm Mark, the triage nurse on duty tonight. Could you please confirm your name and date of birth?
Patient Details: Yes, I'm Fred Yates, born on April 16, 1962.
Triage Assessment
Blood Pressure Check: Let's check your blood pressure while we talk to save time. Please use your left arm.
Medical History: Patient returned from a recent cruise and has been experiencing severe symptoms for over a week.
Presenting Symptoms
Gastrointestinal Issues: Patient reports continuous vomiting of yellow bile, ongoing diarrhoea that's watery with mucus, and inability to retain fluids or food.
General Condition: Symptoms include headache, lethargy, and overall malaise.
Further Examination and Action
Dehydration Assessment: Skin tenting observed, suggesting possible dehydration due to fluid loss.
Plan: Immediate referral to A&E for evaluation and likely treatment of dehydration.
Conclusion
Next Steps: Patient will be provided with a wheelchair to facilitate transfer to A&E for prompt medical attention.
Additional Information: No chest pain reported; rib pain attributed to frequent vomiting.