[18M] With persistent cold, diarrhea, and oral sores

Patient Description

An 18-year-old male has been experiencing a persistent cold for the last month, characterized by nasal congestion that clears somewhat during the day but worsens at night, and a consistently runny nose with green, liquid-like discharge. The patient also reports persistent diarrhea with mostly solid stools that are lighter in color and cause a burning sensation upon passing, which has been ongoing for a few weeks. Additionally, the patient has developed 1-3 painful sores on the roof of the mouth, which have been present for a few weeks and cause a burning sensation. The patient has no known allergies or adverse reactions to medications and is not currently on any medications. Past medical history includes knee surgery approximately 2 years ago and kidney surgery for a ureteral stricture about 10 years prior. No pre-existing conditions have been reported.

Arora's Assessment

What might be happening

Based on the information you've provided, possible diagnoses include:

Upper Respiratory Infection (Common Cold): Characterized by symptoms such as a runny nose, congestion, and sore throat. The green color of your nasal discharge suggests that your body is fighting off an infection.
- Treatment typically involves rest, hydration, and over-the-counter remedies to manage symptoms. Antibiotics are not effective against viruses, which are the most common cause of colds.
Gastroenteritis: An inflammation of the lining of the intestines caused by a virus, bacteria, or parasites. This could explain your diarrhea and the burning sensation during defecation.
- Treatment usually involves rest, hydration, and eating bland, easy-to-digest foods until your symptoms improve.
Oral Ulcers (Canker Sores): These are small, shallow lesions that develop on the soft tissues in your mouth or at the base of your gums. They can make eating and talking uncomfortable.
- Treatment usually isn't necessary for canker sores, as they tend to clear up on their own within a week or two. Over-the-counter topical products and mouth rinses may provide temporary relief.

What you can do

Rest and hydrate: These are the most important steps in recovering from both a cold and gastroenteritis.
Over-the-counter remedies: For your cold symptoms, consider using a decongestant or saline nasal spray. For your diarrhea, consider an over-the-counter medication like loperamide (Imodium).
Oral care: Rinse your mouth with a saltwater solution or over-the-counter mouth rinse to help with your canker sores. Avoid spicy, acidic, or hard foods that can irritate your sores.

What you should look out for

Please seek immediate medical attention if you experience:

Severe, persistent, or bloody diarrhea
Signs of dehydration, such as excessive thirst, dry mouth, little or no urination, severe weakness, dizziness, or lightheadedness
Difficulty swallowing or severe pain from your canker sores
Symptoms that persist for more than a week or get worse

Remember, this advice is intended to be general in nature, and specific causes may need different management. Always consult with a healthcare provider for appropriate treatment.

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1 yr ago

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