PRESENTATION
KHO, ROSCELIE L.
PDR 3 BLOCK 2
DATE: AUGUST 23, 2016 at 2:30pm
% RELIABILITY: 93%
GENERAL DATA
K.B. 2 years old, Male
Filipino
Roman Catholic
DIARRHEA
HISTORY OF PRESENT ILLNESS
5 days PTA
Intermittent low grade fever, Tmax: 39oC
Associated symptoms:
Increase thirst
Poor appetite
Slight irritability
Disturbed sleep
HISTORY OF PRESENT ILLNESS
4 hours PTA
Fever subsided.
Diarrhea: watery, avocado-green color, foul, non blood tinged, non greasy, 1-2
cups per defecating episode, total 3 episodes, 3-4 hr interval.
Vomiting: non projectile, non blood streaked, non foul smelling, cup per
episode, total of 2 episodes, minutes apart.
Associated symptoms:
Sunken eyeballs
Irritability
Increased thirst
Poor appetite
Disturbed sleep
PRE-NATAL HISTORY
Mother, 25 years old, G2P1 (1001)
Pre-natal care:
18 weeks AOG at Upper Laguerta Health Center
Subsequent: regular at Upper Laguerta Health Center
Laboratory tests:
CBC, U/A, HBsAg, FBS, Pap Smear and UTZ: unremarkable
Vitamins: unrecalled.
Immunizations: unrecalled.
NSVD
Good cry
No complications noted
FEEDING HISTORY
Exclusive breastfeeding for 2 weeks.
Formula feeding:
Enfalac: up to 6 months
Promil: up to 1 year
Progress Gold: up to 2 years
Bear brand/ Nido at present.
3 months old
Lifts head and chest with arms extended
Sustained social contact
4 months old
Laughs
Reaches and grabs objects and places them in mouth
GROWTH AND DEVELOPMENT
5 months old
Transfers object from hand to hand
6 months old
Sits with support
7 months old
Responds to tone of voice
GROWTH AND DEVELOPMENT
12 months old
Stands alone
24 months old
Combines 2 words
Can imitate actions
Understand simple instructions
IMMUNIZATION HISTORY
Sibling:
4 years old, male, alive and well.
Heredofamilial disease:
Diabetes mellitus
Hypertension
Stroke
PERSONAL AND SOCIAL HISTORY
Mother deceased, 1 year ago.
SKIN: rashes, lumps, sores, itching, dryness, color change, changes in hair or nails.
EYES: Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double
vision, blurred vision, spots, specks, flashing lights, glaucoma, cataracts.
Throat (or mouth and pharynx): Condition of teeth, gums, bleeding gums, dentures, if any, and how
they fit, last dental examination. Sore tongue, dry mouth, frequent sore throats, hoarseness.
CARDIOVASCULAR: Heart trouble, high blood pressure, rheumatic fever, heart murmurs, chest pain or discomfort,
palpations, dyspnea, orthopnea, paroxysmal, nocturnal dyspnea, edema, past electrocardiographic or other heart
test results.
GASTROINTESTINAL: Trouble swallowing, heart burn, appetite, nausea, bowel movements, color and size of
stools, change in bowel habits, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea.
Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver or gallbladder trouble,
hepatitis.
URINARY: Frequency urination, polyuria, nocturia, urgency, burning or pain on urination, hematuria, urinary
infections, kidney stones, incontinence: In males, reduced caliber or force of the urinary stream, hesitancy,
dribbling.
GENITAL: MALE: Hernias, discharge from or sores on the penis, testicular pain or masses, history of sexually
transmitted diseases and their treatments. Sexual habits, interest, function, satisfaction, birth control methods,
condom use, and problems. Exposure to HIV infection.
REVIEW OF SYSTEMS
PERIPHERAL VASCULAR: Intermittent claudication, leg cramps, varicose veins, past clots in the
veins.
MUSCULOSKELETAL: Muscle or joint pains, stiffness, arthritis, gout and backache. If present,
describe location of affected joints or muscles, presence of any swelling, redness, pain, tenderness,
stiffness, weakness, or limitation of motion or activity; include timing of symptoms (for example,
morning or evening), duration, and only history of trauma.
HEMATOLOGIC: Anemia, easy bruising or bleeding, past transfusions and/or transfusion reactions.
ENDOCRINE: Thyroid trouble, heat or cold intolerance, excessive sweating, excessive thirst or
hunger, polyuria, change in glove or shoe size.
Vital Signs
BP: 90/70 mmHg, R arm
PR: 100bpm, R radial, regular, bounding
RR: 25cpm, normal depth
Temp: 37.1oC, right axilla
PHYSICAL EXAMINATION
Anthropometric Measurements
Weight: 10kg
Height: 87.5 cm
Ears
o Inspection:
Symmetrical, (-) gross deformities
o Palpation:
(-) tenderness
o Otoscopy:
Intact tympanic membrane
PHYSICAL EXAMINATION
Eyes
o Inspection:
Eyebrows - black, (-) scaling, (-) hair loss
Orbital rim - symmetric, (-) swelling
Lid closure - complete
Eyelashes- (-) hair loss, (-) crusting
Sclera - anicteric
Conjunctiva - pink
Cornea - smooth, (-) opacities
Pupils isocoric, (+) direct and consensual pupillary reflex
o Palpation:
Tonometry normal, soft
o Ophthalmoscopy:
(+) ROR on both eyes
o EOM:
Full range of motion
PHYSICAL EXAMINATION
Nose
o Inspection:
Symmetric, septum in midline, pink nasal mucosa (-) nasal flaring
o Palpation:
(-) pain
Sinuses non-tender
Breast/Axilla/Nodes
Inspection:
(-) lesions, (-) discharge, (-) inflammation
Palpation:
No enlarged lymph nodes
PHYSICAL EXAMINATION
Chest and Lungs
Inspection:
Symmetric chest walls, (-) gross deformity
Palpation:
(-) mass, (-) tenderness
Percussion:
Resonant in all lung fields
Auscultation:
Clear breath sounds
Cardiovascular
Inspection:
(-) deformities, (-) jugular vein distention
Palpation:
Regular pulses, (-) thrills,
PHYSICAL EXAMINATION
Percussion:
(-) cardiac border enlargement
Auscultation:
Normal s1 and s2, (-) murmurs
Abdomen
Inspection:
non-protuberant, (-) visible peristalsis, (-) hernia, (-) distention
Palpation:
(-) mass, (-) tenderness, (-) guarding
Percussion:
Tympanitic all throughout
Auscultation:
Normoactive bowel sounds, 25 cpm
PHYSICAL EXAMINATION
GUT
Inspection:
Grossly female, (-) lesions
Musculoskeletal
Inspection:
(-) gross deformities, (-) swelling
Palpation:
(-) tenderness
Palpable peripheral pulses
PHYSICAL EXAMINATION
Neurologic
Mental Status
Conscious, alert
Cranial Nerves
II: regards face and able to follow an object with gaze correctly
III, IV, VI: good pupillary reaction to light. Full EOM in the 6 cardinal gazes
with no nystagmus
V: patient is ticklish to light touch and reacts to pain
VII: no facial weakness, face is symmetric
VIII: patient responds to whispered voice
IX, X: uvula is midline, symmetrical elevation of posterior pharynx. No voice
hoarseness
XI: patient can shrug shoulders and turn head
XII: no atrophy or fasciculation in tongue. Tongue is in midline
PHYSICAL EXAMINATION
Motor
Gait ambulatory, with steady balance and gait
Coordination able to perform finger-to-nose test
Muscle strength: 5/5
Reflexes: 2+
SUMMARY OF IMPORTANT FINDINGS
5 days PTA, onset of fever
Intermittent, Tmax= 39C
Associated symptoms:
Irritability
Increased thirst
Anorexia
Disturbed sleep
Slightly sunken eyeballs
ACUTE VIRAL
GASTROENTERITIS WITH
SOME DEHYDRATION
BASIS FOR IMPRESSION
Fever
Watery diarrhea
Vomiting
Rotavirus common in children
(-) rotavirus vaccination
Irritability
Weakness
Decreased appetite
Slightly sunken eyeball
At 5th hospital day, patient appears well, (-) signs of some
dehydration
DIFFERENTIAL DIAGNOSES RULE IN RULE OUT
(-) bloating
(-) intesnse abdominal cramping
(+) diarrhea
(-) headache
(+) fever
FOOD POISONING (-) bloody stools
(+) vomiting
(-) erythema nodosum
(-) oral lesions
ACUTE VIRAL GASTROENTERITIS
Group A rotavirus causes 25-65% of severe infantile gastroenteritis
worldwide.
ETIOLOGY
Most common viral pathogen : Rotavirus
Person-person contact
Watery diarrhea
Fever
Fecalysis
Urinalysis
MANAGEMENT
Therapeutic
Adequate IV fluid replacement
Weight: 10 kg
Holiday Segar Formula = 1000ml/kg if 0-10kg
= 1000ml
= 1000 ml/day
W/ some dehydration = 10 X 60
= 600 ml
Total = 1000 ml + 600 ml
= 1, 600 ml/day or 67 ml/hr
Continue Bacillus clausii (Erceflora) 2 billion/5ml oral suspension 2 ampules
per day
DIET: BRAT; no dairy products; DAT afterwards
Continue probiotics (Yakult)
Discharge if stable
MANAGEMENT
Education
Inform the guardian about the importance of continuing to feed the
patient.