Date and Time of Interview:

June 14, 2016

Source of Information:
Patient
Reliability:
95%
Source of Referral:
Pinabacdao RHU
IDENTIFYING DATA
Pacayra, Leo, 32 years old, male, cohabiting, Roman Catholic, Filipino, a farmer
residing at Pinabacdao, Samar admitted for the first time at EVRMC.
CHIEF Complaint: Diarrhea and Vomiting
Morning prior to admission, the patient had 8-10 bouts of diarrhea characterized as
watery, non-bloody stool amounting to 500-800 mL per bout. It was associated with nonprojectile vomiting 8x amounting to 300-500 mL per vomit, no fever. No medications taken.
Just replaced losses with water. Decreased urine output noted with less than 240 cc per
urination. No consult done. Prior to episode of vomiting and diarrhea, patients last meal was
fish and rice only. No other member in the family had episodes of vomiting and diarrhea that
day but last week his wife and child had episodes of vomiting and diarrhea as well.
The
patients symptoms persisted and now with body weakness so he was brought to
Pinabacdao RHU, medications given (unrecalled) but was referred to EVRMC hence
admission.
PAST MEDICAL HISTORY

Childhood Illnesses: (+)measles, (-) chickenpox, (-) mumps

Adult Illnesses:
Medical: No previous hospitalization
Surgical: No previous surgical operations.
Psychiatric: none
Immunizations: unrecalled
No known allergies to food or drugs; no previous blood transfusions.

FAMILY HISTORY
With paternal history of Hypertension. No family history of cardiovascular disease,
DM, cancer, bronchial asthma, thyroid disease, seizure disorder, or mental illness.
PERSONAL AND SOCIAL HISTORY

The patient was born and raised at Pinabacdao, Samar. He was not able to go to
school and worked as a farmer. Their source of drinking water is from a deep well. They dont
have a toilet facility. They practice open defecation just few meters away from their house.
The patient is an occasional smoker and alcoholic drinker. He is not active in any social
organization.
REVIEW OF SYSTEM
General: with body weakness, no fever
Skin: No rashes, no sores, no itching, no dryness.
Head: had dizziness, lightheadedness, and no head injury.
Eyes: No double vision, no pain, no redness, no excessive tearing, no blurring of vision.
Ears: No tinnitus, no vertigo, no discharges, no pain, no hearing loss.
Nose: No itching, no colds, no epistaxis, no sinusitis.
Mouth & Throat: no swelling gums, no bleeding, no dryness, no sore throat, no dysphagia,
and no hoarseness of voice.
Neck: No swollen glands, no lumps, no pain, no stiffness.
Breasts: No pain, no lumps, no nipple discharge.
Respiratory: no cough, no dyspnea, no hemoptysis.

Cardiovascular: No chest pain, no palpitations, no orthopnea, no paroxysmal nocturnal

dyspnea.
Gastrointestinal: yellow watery stool amounting to 500 mL per bout x 8, no abdominal pain
Urinary: no polyuria, no nocturia, no hematuria, no dysuria, and no incontinence.
Genital: No hernia, no discharge, no itching, no sores, no redness.
Peripheral Vascular: No intermittent claudication, no cramps, no varicose veins, no
redness.
Musculoskeletal: No joint pains, no swelling, no redness, no backache.
Neurologic: No fainting, no seizures, no numbness, no tingling sensation, no tremors, no
vertigo.
Hematologic: No easy bruising, no active bleeding, no history of blood transfusion.
Endocrine: No heat and cold intolerance, no excessive sweating, no polyuria, no polydipsia,
no polyphagia.
Psychiatric: No nervousness, no tension, no depression, no mood swings.
PHYSICAL EXAMINATION (1st day of hospitalization)
General Survey: Patient seen sitting on bed with IVF at left and right metacarpal vein,
conscious and coherent, oriented to time, place and person, cooperative, well-groomed,
endomorph, not in cardio-respiratory distress, afebrile and with the following vital signs:
BP- 100/60 mmHg HR- 92 bpm PR- 92 bpm

RR- 22 cpm Temp- 37 C

Integument:
Skin- Brown complexion, wrinkled, delayed skin turgor, no hypo nor hyper pigmentation,
no rashes, no lesions.
Nails Pale, capillary refill of more than 3 seconds
Head:
Scalp No engorged veins, no scars, no lesion, no tenderness.
Hair Short, black, evenly distributed, neither lice nor nits.
Skull Normocephalic, symmetrical, atraumatic.
Eyes:
Sunken eyeballs
pale palpebral conjunctiva, anicteric sclerae
Pupils Equally Rounded and constricts to 3 mm and briskly reactive to direct and
consensual light.
EOM Intact, full movement.
Ears: Symmetrical, no impacted cerumen, no abnormal discharges, no swelling, no
tenderness, no hearing loss.
Nose and sinuses: No septal deviation, no nasal flaring, no lesion, no discharge, no sinus
tenderness.
Mouth and Throat: Pale and dry lips, no sores, no fissures, pale buccal mucosa, no
bleeding gums, tongue moves freely, no ulceration, uvula at midline, no enlargement of
tonsils.
Neck: No venous engorgements, trachea at midline, enlarged, no enlarge lymph nodes.
Chest and lungs:
Inspection: Truncal in shape, no bulging, no retraction of subcostal and intercostal muscles,
symmetrical lung expansion.
Palpation: Confirmed symmetrical lung expansion, no masses.

Percussion: Resonant in all lung fields.

Auscultation: clear breath sounds in all lung fields, no crackles, no wheezing, and no pleural
friction rub
Heart:
Inspection: adynamic precordium
Palpation: PMI palpable at 5th ICS left MCL, no thrill, no heaves.
Auscultation: regular rhythm, synchronous with the pulse
Abdomen: soft non tender abdomen
Inspection: Symmetrical
Palpation: flat abdomen, hyperactive bowel sounds. Spleen not palpated. Liver margin at
10cm at right MCL and 2cm at right subcostal margin. Liver edge not palpated. No
tenderness in all quadrants.
Extremities:
Inspection: peripheral pulses thready and fast. No edema. No tenderness.
Back and Spine:
Inspection: No abnormal deviation, no bulging.
Palpation: No tenderness, no mass.
IMPRESSION: ACUTE GASTROENTERITIS WITH SEVERE DEHYDRATION
Basis:
Watery, non-bloody, foul smelling
Stool 8 bouts amounting to 500mL/bout
Non- projectile vomiting 300-500 mL
Sunken eyeballs
Fast and thready pulse
Delayed Skin Turgor
Dry mouth and oral mucosa
Differential Diagnosis:
Cholera ruled in because of the presence of diarrhea. Ruled out because the stool should
be rice-colored and not foul smelling
Shigella considered because he had diarrhea. Ruled out because patients infected have
bloody diarrhea or dysentery.
Vibrio parahemolyticus infection considered because patient presented with watery
diarrhea but ruled out because there was no abdominal pain.
S. aureus considered because patients infected with these pathogen presents with
vomiting and diarrhea.
Diagnostics:
Stool exam to check for ova and parasites
S Na. K to check for electrolyte imbalance brought about by the GI losses
Creatinine to check for acute kidney injury

Therapeutics:
Hydration
2 IV lines: PLR 1L to run for 1 hour and PNSS 1L to run for 2 hours
Others:
Hydration
Monitor intake and output