Professional Documents
Culture Documents
Prior to admission (PTA), patient experienced loose bowel movement characterized by 3 episodes
of greenish watery stool estimated to be half cup in amount each. The patient’s mother also reported that
the patient was feverish. Patient’s last intake was milk. Water source of the patient at home is from tap.
No other family members sick. Current medications taken by the patient include folic acid, micro
vitamins and diphenpherox(?)
The patient was diagnosed of Thalassemia at estimated 1-2 mos. old back in 2005. He has been in
and out of the hospital ever since. The patient then underwent splenectomy last May 2017. Patient has no
known allergies noted
Patient has history of measles and mumps. The patient is fully immunized and has asthma. He
also underwent splenectomy last May 2017.
FAMILY HISTORY:
Patient has relatives with Hypertension, Stroke, Diabetes Mellitus, Asthma and Cancer. The
patient’s maternal grandmother died of colon cancer.
Patient is an only child. The patient stopped going to school for the reason that he often passes
out secondary to his disease condition. He lives with his mother and father on the first storey of their
house while his other relatives lives on the second floor. The patient likes to play with his tablet during
his free time. He also likes to hangout with other children in his neighborhood.
FEEDING HISTORY:
Patient has been bottlefed until 6 mos, introduced to semi-solid foods thereafter. According to the
patient’s mother, the patients usually consumes up to 6 bottles of milk daily and doesn’t usually eat
normal foods charot. The patient also likes to eat cookies and chocolate milk.
REVIEW OF SYSTEMS:
❖ GENERAL SURVEY: Patient is bedridden, awake, conscious and responsive with a GCS of 15,
patient is oriented to time and place and obeys command.
❖ SKIN: Some scarring and observed during examination in the lower extremities. Nails are
without clubbing and capillary refill time is less than 2 seconds and with poor skin turgor.
❖ HEENT: The head is symmetrical with equal hair distribution no lumps and tenderness upon
palpation. Eyes are equal, round and reactive to light accommodation, sclera is icteric and the
palpebral conjunctiva appears pale. No periorbital swelling in both eyes nor excessive tearing and
discharges. No ear deformities and discharges noted. Nasal mucosa is pink, septum is in midline
and no sinus tenderness. Lips are dry and oral mucosa is pink with positive gag reflex and patient
is without dentures and with dental caries.
❖ NECK: A lump noted on right side. Distended jugular neck vein is noted.No goiter or swollen
glands noted.
❖ BACK: No lesions or deformities. Shoulder height is symmetrical, no rashes, bruising or
tenderness.
❖ RESPIRATORY: Thorax is symmetrical with good excursion. Resonant on percussion, with
normal vesicular breath sounds upon auscultation. No redness or lumps on the chest. No
wheezing or rales noted.
❖ CARDIOVASCULAR: JVP was not observed. Heart sounds are normal no murmurs or bruits
noted.
❖ ABDOMEN: Abdomen is globular and distended. Scar on left upper quadrant noted.
Normoactive bowels sound on auscultation with a rate of 7 bowel sounds per minute. Tenderness
was noted on right lower quadrant. Hepatomegaly was also noted.
❖ GENITALIA & RECTAL: Not assessed
❖ EXTREMITIES: Warm and with traces of pitting edema on the lower extremities. No stasis
pigmentation or ulcers. Bruises noted on the left lower extremity.
❖ MUSCULOSKELETAL: No joint deformities. Good range of motion in hands and wrist.
❖ NEUROLOGIC: Weak but cooperative. Oriented to time and place, obeys command and has
spontaneous eye opening. GCS of 15
CLINICAL IMPRESSION
ACUTE GASTROENTERITIS
DIFFERENTIAL DIAGNOSIS:
● DIARRHEA ● VOMITING
● ABDOMINAL DISCOMFORT
● FEVER
AMEBIASIS
● ●
CROHN’S DISEASE
● ●
ULCERATIVE COLITIS
● ●
CHOLERA
● ●
PARACLINICALS
FECALYSIS
URINALYSIS
ELECTROLYTE PANEL
CBC
LIVER ENZYMES??
HEMO- COAGULO
MANAGEMENT
1. Replace fluid loss by initiating an IV line to facilitate fluid replacement
2. Consider antibiotic therapy if disease is confirmed as bacterial in nature
3. Administer anti-pyretics for fever
4. Assess for any untoward complications
5. Encourage adequate fluid intake and nutrition