Acute gastroenteritis

By: Madhavi pandya

Priyanka nandi
General data
This is the case of AC 1y/o male, roman catholic, presently residing at
City of san Fernando, la union. He admitted for 1st time in this
institution.
Informant: mother
reliability: 95%
Chief complaint
Loose bowel movement
History of present illness
1 day prior to consult , patient had 5 episodes of loose bowel
movement watery and yellowish in color with associated fever of
undocumented temperature and poor appetite. No vomitting , cough
,& colds were found. Consult was done in this institution and was sent
home with prescribed ORS.
Few hours prior to admission patient had the same condition with
loose bowel movement and fever. Hence, admission.
 Prenatal history:
The mother was 37y/o, G5P5(5005),prenatal check up
instituted at 16 weeks AOG , she had total 5 prenatal checkups done
regularly.
Natal history:
patient was breastfed with good suck.hospital stay 3 days
umbilical stump fell of after 5 days without infection . newborn screening
results normal.
Feeding history:
patient was breastfed per demand up to 6 months old.
complementary milk was given at 6 months old . semisolid foods were
introduced at 6 months. At present sample diet includes
rice,meat,noodles,egg,vegetables,fish.
Growth and development
Birth weight: 3.2 kg
Present weight: 7.3 kg
Present height: 123 kg
Developmental milestones are as per age.
Immunization
BCG
DPT
HEPA B
Past medical history
Past hospitalization: none
Childhood illness: (+) measeles
Allergies: none
Current medication: multivitamins
 Family history: (-) allergies ,(-) asthma ,(-)hypertension,(-) malignancy
Social and personal history:
Father is 34y/o currently working as construction worker ,graduate of
elementary .
Mother is 38 y/o currently working as market vendor , graduate of
highschool.
 Review of system:
General survey: no weight loss,pallor,fever,chills,(+) poor appetite
Integumentary: no cyanosis,pallor,rashes,petechiae
Head and neck: no lesions, trauma,swelling,anicteric sclerae,nonsunken
eyeballs,(-) ear/nasal discharge,(-) tenderness
Respiratory : no dyspnea,cough,sputum
Cardiovascular: no edema,cyanosis,murmur
Gastrointestinal: poor appetite,(+) diarrhea ,no nausea,melena
Urinary and renal: no dysuria , oliguria ,hematuria
Genital: no pain swelling,discharge
Musculoskeletal : no deformities ,pain , swelling,tenderness
Endocrine and metabolic: no polydipsia , polyphasia
Hematologic: no anemia,bleeding,bruising, transfusion
Nervous system: no seizure,dizziness ,tremors
 Physical examination
General appearance : awake, febrile ,not in cpd
Vital signs: BP- 110/70
CR-121
RR-26
TEMP-37.9
Anthropemetric measurements: weight:9.3kg
height:57cm
BMI:
 Skin: warm to touch ,good skin turgor, no rashes , petechiae
HEENT: no scars ,lesions , deformities
Eyes: sunken eyeballs , anicteric sclera,pink palpebral conjunctiva
Ears :normally set, no discharge, intact tympanic membranes
Nose: no discharge , congestion
Mouth and pharynx: moist lips& buccal mucosa , no ulcers ,dental caries
Neck: (-) CLAD, tenderness
Chest & lungs: symmetric chest expansion , no lagging , retraction, clear
breath sound, no crackles ,wheeze
Heart: adynamic heart precordium ,PMI at 4th ICS LMCL with normal rate
and regular rhythm ,no murmur
Abdomen: flat ,non distended ,NABS ,tympanic ,soft ,nontender
 Genitalia : grossly male ,SMR normal
Exremities: no deformities ,good peripheral pulses ,good capillary refill
time
Neurologic exam: alert ,responsive
cerebellum function: no tremors ,ataxia
Cranial nerve function test: normal
Negative babinki sign ,ankle clonus ,kernings sign ,brudzinki sign
Admitting diagnosis
Acute gastroenteritis with some dehydration
Sunken eyeballs
Diarrhea
Poor appetite
fever
 Diagnostic : cbc ,pc ,urinalysis
Theraputic : paracetamol 120 mg/5ml
Final diagnosis
Acute gastroenteritis with some dehydration