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NURSING HISTORY

MS is a female 2year of age, a roman catholic, was born on november 21,2008 presntly
residing at bocaue bulacan. She experience watery stool and vomiting which eventually
made her family sought for admission.

HISTORY OF PRESENT ILLNESS

Three day prior to admission, patient experienced on and diarrhea and vomiting,
no consultation and medicines given to the patient at home. Until 2 days prior to
admission patient was positive of several episodes of LBM, yellowish to greenish in
color, mucoid, non blood streaked and positive fever again no consultation done. Upon
admission, With admitting vital signs of CR- 140bpm, RR- 25cpm, Temp- 36.4˚C.

PAST HISTORY

No hospitalization before

FAMILY HISTORY

No heriditary history

SOCIAL HISTORY

Bb. M.S was born November 21,2008. He was the youngest of the 2 children in
the family. Two weeks prior to admission Bb. M.S together with his siblings were left
by their mother. While his father was a hardworking businessman.The income of his
father is just enough to support their basic needs.
ANATOMY AND PHYSIOLOGY:

DIGESTIVE SYSTEM
The digestive system consists of two linked parts: the alimentary canal and
theaccessory digestive organs. The alimentary canal is essentially a tube, some
9meters (30 feet) long, that extends from the mouth to anus, with its longest section-the
intestines- packed into the abdominal cavity. The lining of the alimentary canal
iscontinuous with the skin, so technically its cavity lies outside the body. Thealimentary
‘tube’ consist of linked organs that each play their own part in digestion:mouth, pharynx,
esophagus, stomach, small intestine, and large intestine. Theaccessory digestive
organs consist of the teeth and tongue in the mouth; and the salivary glands,
liver, gallbladder, and pancreas, which are all linked by ducts to the

alimentary canal.
STOMACH
It is a J- shaped enlargement of the GI tract directly under the diaphragm
inthe epigastric, umbilical and left hypochondriac regions of the abdomen.Whenempty, it
is about the size of a large sausage; the mucosa lies in large folds,
calledRUGAE.Approximately 10 inches long but the diameter depends on how much
foodit contains.When full, it can hold about 4 L ( 1 galloon) of food.Parts of thestomach
includes cardiac region which is defined as a position near the heartsurrounds the
cardioesophageal sphincter through which food enters the stomachfrom the
esophagus;fundus which is the expanded part of the stomach lateral to thecardia
region;bod y is the mid portion; and thepylorus a funnel shaped which is theterminal
part of the stomach.The pylorus is continuous with the small intestinethrough the pyloric
sphincter, or valve.
With the gastric glands lined with several secreting cells the zymogenic(peptic)
cells secrete the principal gastric enzyme precursor, pepsinogen.Theparietal (oxyntic)
cells produce hydrochloric acid, involved in conversion ofpepsinogen to the active
enzyme pepsin, and intrinsic factor, involved in theabsorption of Vitamin B12 for the red
blood cell production. Mucous cells secretemucus.Secretions of the zymogenic, parietal
and mucus cells are collectively calledthe gastric juice.Enteroendocrine cells secrete
stomach gastrin, a hormone thatstimulates secretion of hydrochloric acid and
pepsinogen, contracts the loweresophageal sphincter, mildly increases motility of the GI
tract, and relaxes thepyloricsphincter.Most digestive activity occurs in the pyloric region
of the stomach.After food has been processed in the stomach, it resembles heavy
cream and iscalled CHYME.The chyme enters the small intestine through the pyloric
sphincter.
LABORATORY

CLINICAL MICROSCOPY 1

normal result

RBC F 4.5-5.5mom

M 5.5-6.5 mL/mom

HgB F 120-140gL 114gL

M 140-160gL

HEMATOCRIT F 0.10- 0.12L o.371L

M 0.10-0.43L

WBC 5.0-10x10 gL 8.9x10^gL

PLATELETS 180-290x10 12/L 207x10^12L

E.SED RATE F 0-20 mm/hr

M 0-9mm/hr

Bleeding time 1-5mins

Coagulation time 2-6mins

FECALYSIS
COLOR: Yellow

Characteristics: soft

Reaction: acid

Ova of parasite: Negative

Occult blood

RBC: none

Pus cell: none

CLINICAL MICROSCOPY 1
WBC 0-14 1hpf

RBC 0-1 1hpf

E.cells : occasional

A. urates : moderate

Color : yellow

Characteristics; hazy

Reaction: acid

Specific gravity : 1 mm

Protein: negative

Sugar : negative