To evaluate a patient with diarrhea, the practitioner differentiates symptoms and makes clinical judgments. This triage function is based on the patient’s responses to questions designed to help determine the cause of the specific signs and symptoms, their characteristics, and their severity. The practitioner should therefore ask the patient about vomiting, high and/or prolonged fever, and other symptoms to determine the patient’s susceptibility to complications. Persistent diarrhea, chronic diarrhea, or presence of high fever (greater than 102.2°F |39°C]), protracted vomiting, abdominal pain in patients older than 50 years, or blood or mucus in the stool precludes self-treatment and requires immediate medical referral. If none of these significant findings is present, the degree of dehydration is the next important assessment; the practitioner should ask about the nature and amount of fluid intake. Severity of dehydration can be accurately assessed by evaluating changes in body weight. For example, in children, mild dehydration is associated with a 3% to 5% loss of body weight, whereas severe dehydration is associated with a loss of more than 9%. However, the patient (or the parent) seldom knows the exact premorbid weight for comparison, and distinguishing between mild and moderate dehydration may be difficult.

The initial assessment of a pediatric patient should also seek to determine plausible causes of the symptoms. The common symptoms of acute gastroenteritis (e.g., vomiting, loose stools, and fever) are nonspecific findings associated with many other childhood diseases (e.g., acute otitis media, bacterial sepsis, meningitis, pneumonia, and urinary tract infections). This information is key to recommending a proper course of action, which may include self-treatment or referral to a primary care provider. A complete medication history must be assessed before a product is selected.

Physical assessment of a patient with complaints of diarrhea can provide information useful in assessing severity of the diarrhea. Checking skin turgor and moistness of oral mucous membranes will help determine the degree of dehydration. Vital signs (e.g.. pulse, temperature, respiration, and blood pressure) are important indicators of illness severity and should be routinely measured. Symptoms of moderate-to-severe dehydration may include postural (orthostatic) hypotension, defined as a drop in the systolic and/or diastolic pressure of greater than 15 to 20 mm Hg on moving from a supine to an upright position. Normally, the diastolic pressure remains the same or increases slightly, and the systolic pressure drops slightly on rising. If the blood pressure drops, the pulse should be checked simultaneously; the pulse rate should increase as blood pressure drops. Failure of the pulse to rise suggests the problem is neurogenic (e.g., diabetic patients with peripheral neuropathy) or the patient is taking a beta-blocker. The presence of orthostatic hypotension suggests that the patient has lost 1 liter or more of vascular volume, and referral for medical care is necessary.

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