CASE ANALYSIS FOR ACUTE GASTROENTERITIS

Acute gastritis is a sudden inflammation or swelling in the lining of the stomach. It can
cause severe and nagging pain. However, the pain is temporary and usually lasts for short bursts
at a time.

General Data

Name: Isabelina Sugay

Age: 14 years old
Address: Kalookan City
Nationality: Filipino
Religion: Catholic
Chief complaint: Diarrhea
Admitting Diagnosis: Acute Gastroenteritis with moderate sign of dehydration

Physical Assessment

Patient is conscious, coherent, oriented to time, place and person. Ambulatory, afebrile,
not in cardiorespiratory distress. Pink palpebral conjunctiva, anictenic sclera, no jaundice, no
cyanosis, capillaryrefill <2 secconds, good skin turgor, elastic, warm to touch, symmetrical chest
expansion, clear breath sounds, adynamic precardium, negative in rales, normal rhythm.

Past Medical History

She has history of measles, no history of mumps and chicken pox. She has previous admission
due to dengue last 2011.

Allergic to: Bagoong and shrimp

History of Present Illness

11 hours prior to consult abdominal pain in all regions of her abdomen. With pain scale
of 5/10. Symtoms is accompanied by vomiting and diarrhea. She vomits 6 times and she has 10
loose stool bowel movement. She has loss of appetite and weakness. Patient takes loperamide 2
times but her condition is still the same which made her sought consent.
 Laboratory Exams

Normal values Result Interpretation

WBC 4.8-10.8 15.47 Increased wbc may be due to inflammation

of the stomach lining and intestine resulting to
diarrhea.
Neutrophil 40-70 77.20 It is wbc that first respond to infection which
has presence of inflammation of both
intestine and stomach.
Lymphocyte 19-48 14.70 Low level may be due to bacterial infection

Eosinophil 2-8 1.70 Low level means there is inflammation on the

stomach lining and intestine resulting to
acute gastroenteritis

Fecalysis

Result Interpretation

Stool color Yellow

Consistency Watery Patient suffered from diarrhea due to infection . The

microorganisms responsible for infectious gastroenteritis
are a major cause.

Fat globules Few

Others Startch granules

Medications

Drugs Mechanism of Indication Interpretation

Action
Bacillus Clausii- Normal inhibitants of Treatment for diarrhea It inhibits or prevent
tubule the intestines, with no due to infection the spread of bacteria
pathogenic powers. in the stomach and
intestines .
Zinc sulfate It works by replacing Use to treat zinc It was given because
zinc in the body. deficiency it prevent the severity
and duration of
diarrhea and replace
the fluid loss.