Name of Patient: Sabornido, Carlo

Informant: Louann Sabornido (Patients

mother)
Reliability: Fair
Historian: Tolentino, Sofia Klareta
Group:13 B
Hospital: DLS-UMC
Department: Pediatrics
Preceptor: Dr. Regente I. Lapak
Date Taken: June 30, 2014
Date Submitted: July 2, 2014

CLINICAL HISTORY

General Data:
C.S., 4 years old, male, Filipino, Roman Catholic, born on September 12, 2009 in
Dasmarinas, Cavite and currently residing at Sta. Cruz P. Noval, Cavite, consulted at DLS-UMC
for the third time on June 30, 2014 (Monday) at around 2:30pm.

Chief Complaint:
masakit ang tyan

History of Present Illness:
The patient was apparently well until two days prior to consultation, the patient became
nauseous after he took two spoonful of his meal that is accompanied by mild abdominal pain in
the epigastric region and passage of loose, brownish, no peculiar smell, parang gatas na may
bula and watery stool once. After the patient passed stool, the patients epigastric pain
susbsided. The pain scale was not evaluated and there are no associated symptoms like
vomiting, anorexia, melena / hematochezia, perianal itching or fatigue. According to the mother,
the patients pain occurs whenever he eats. No medications or any interventions were given nor
consulted the health care center.
One day prior to consultation, the patient experienced the same epigastric pain and was
relieved when he passed stool characterized by loose, watery, milky like three times in the
morning, which is accompanied by the presence of headache and fever as verbalized by the
mother as hot to touch but was not able to get his temperature. The patients mother put cooling
pad (icool) on the patients forehead and his fever was gone after an hour. There were no
presence of factors that aggravate his condition.
Few hours prior to consultation, the patients mother noticed the patient was hot to touch
but subsided after an hour. He passed out stool once with mild epigastric pain and headache,
which prompted the patients mother to seek medical consult.

Past Medical History:
There was no history of previous hospitalizations. Likewise, there was no history of
asthma, cardiac disease, thyroid disease, liver disease, renal disease, diabetes mellitus, febrile
convulsion, seizure disorder, hepatitis or congenital anomalies. There was no history of previous
injuries or accidents noted. The patient is completely immunized from birth (BCG, Hepatitis B,
DPT, OPV). No allergies to food and medications were noted.


Family Medical History:
The patients grandfather on his mothers side is hypertensive and has cardiomegaly. No
noted cardiac disease, thyroid disease, liver disease, renal disease, diabetes mellitus, cancer,
tuberculosis, allergies, febrile convulsion, seizure disorder or congenital anomalies on both sides
of the patient.


Birth and Maternal History
The patient was born to a G2P2 (2-0-0-2), 19 y/o mother, delivered live, full term via
normal delivery at their lying in clinic barangay health center in Victoria Dasmarinas , Cavite
where she had her complete prenatal care. She had complete shots of tetanus vaccine and she
was also taking multivitamins. There was no exposure to radiation and the patients mother noted
no complications.
The patients mother had 8 hours of labor before the baby was delivered via spontaneous vaginal
delivery in the lying in clinic in their health center with the birth weight of 8 lbs. The APGAR score
was not recalled along with the intervention done in the lying in during the delivery.



Developmental History
At a chronological age of 4, the patient can walk, run up and down the stairs in the
daycare, can stand and run on tiptoe.
He can draw simple shapes like circle, square and can imitate simple drawings using
different shapes. He can give his full name, address, age and smiles when he hears joke. He was
able to give the name of his family members and describe the color that he likes. He was able to
count from 1- 10 and his speech is grammatically correct. According to his mother, he still wants
to be spoon-feed by his mother but can attend to his own toilet needs.

Nutritional History:
The patient was breastfed intermittently until 6 months old due to his mothers lack of
breastmilk. He was given Bonna (1
st
infant milk) whenever she doesnt have enough breastmilk
followed by Bonamil when the baby is 6 months to 12 months. The patients mother started
supplementary feedings when he was 6 months. She shifted to Bonakid from 1 year old until 3
years old.
At present, the patient is eating three meals a day. He prefers chicken for his meal and
doesnt eat vegetables. He eats snacks in the afternoon and likes to eat chichirya as verbalized
by his mother and softdrinks.

Immunization:
Patients mother claimed that all her sons vaccine was updated and complete.
Vaccine Date Given Reaction
BCG At birth
Hepatitis B At birth
DPT 1 OPV 1 Unrecalled The patient experienced fever
but subsided after taking
Paracetamol
DPT 2 OPV 2 Unrecalled
DPT 3 OPV 3 Unrecalled
MMR Unrecalled
Measles 9 months

Personal and Social History:
The patient is currently enrolled in a day care center in Dasmarinas, Cavite. According to
his mother, he is quiet at school but still mingle and plays with the other kids. He is very
industrious at school and at home, he is very caring and sweet to his baby sister.
The patient lives in a one-storey house made up of concrete together with 3 family
member including her mother, father and baby sister. The patient plays with his friends outside
their house in the afternoon. The houses water is supplied by NAWASA and is also used for
drinking. The garbage is regularly disposed and their toilet is flushable.
Patients mother is 24-year-old, housewife, non-smoker and non-alcoholic drinker. The
patients father is 31-year-old, security guard, smokes 10 sticks of cigarette a day and occasional
alcoholic drinker. The patient has a little sister who is 7 months old.


Review of Systems:

General Health: (-) weakness (-) easy fatigability (-) weight loss (-) decreased appetite
when the patient has fever
Integument: (-) pallor (-) wound (-) rashes (-) erythema (-) lesion
(-) hyperpigmentation (-) hypopigmentation
Head and neck: (-) stiffness (-) headache with fever (-) mass (-) dizziness (-) swelling
Eyes: (-) icteric sclera (-) pain (-) redness (-) mass (-) lesion (-) discharge
Ears: (-) otalgia (-) disturbance in hearing (-) vertigo (-) tinnitus (-) mass (-)
lesion (-) discharge
Nose and Sinuses: (-) colds (-) mass (-) obstruction (-) lesion (-) discharge (-) epistaxis
Mouth and Throat: (-) dysphagia (-) toothache (-) hoarseness (-) ulcers (-) tongue
fasciculations (-) sore throat
Breasts: (-) mass (-) lesion (-) discharge
Respiratory Tract: (-) dyspnea (-) cough (-) chest pain (-) crackles (-) wheezes (-) phlegm
Cardiovascular: (-) chest pain (-) palpitations (-) easy fatigability (-) edema
Gastrointestinal: (-) anorexia (-) nausea (-) vomiting (-) constipation (-) diarrhea
(-) abdominal distension (-) abdominal pain (-) melena (-) hematemesis
(-) hematochezia (-) retching (-) colic
Genitourinary: (-) polyuria (-) oliguria (-) nocturia (-) dysuria (-) flank pains (-) palpable
mass
Hematopoietic: (-) pallor (-) easy fatigability (-) easy bruising (-) easy bleeding
Musculoskeletal: (-) Edema (-) weakness (-) fractures (-) joint pains (-) leg spasm
Nervous: (-) drowsiness (-) speech problem (-) tremors (-) seizure (-) syncope
Endocrine: (-) polyphagia (-) polydipsia (-) polyuria (-) diaphoresis (-) heat
intolerance
Autonomic deficiency: (-) fecal incontinence (-) urinary incontinence

PHYSICAL EXAMINATION

General Survey:
The patient is fairly developed, fairly nourished, conscious, coherent, oriented to place
and person, with no cardio-respiratory distress, and appears to his stated chronological age of 4
years old. Has no IV line, foley catheter, nasal cannula, NGT or endotracheal tube.

Vital Signs:

Vital Signs

VS of the patient 1 year and
9 months old
Normal values of 6 years old

Pulse rate 114 bpm (Right radial pulse) 80-120bpm
Heart rate 119 bpm 80-120 bpm
Respiratory rate 32cpm 12-20 cpm
Temperature 36.8C (otic) 36-37.5
Blood pressure 90/60 mmHg (Right arm) Systolic: 99-110 Diastolic: 55-
70

Anthropometric Measurements:

Anthropometric
Measurement
Actual
Values
Ideal
Values
Z score Percentile
rank
Nutritional
Classification
Weight


38 lbs/
17.25 kgs
16 kgs 0- -2 33
rd
percentile
Not wasted/
overweight
Height

109 cm 100cms 0-1 55
th
percentile Not stunted
BMI

14. 52 0- -1 33
rd
percentile Normal
Chest
Circumference
53 cm CC>HC N/A N/A Normal
Head
Circumference
51 46-94 N/A N/A Normal


Ideal body weight computation for Children 2 years and up:

Weight in kg = age in years x 2 + 8
= 4 x 2 +8
= 16 kgs

Waterlow classification for wasting

Actual weight
X 100
Ideal weight for actual height

= 17.25 kg/ 16kg x 100
= 107.81% --- normal





CLASSIFICATION
Normal 90%
Mild 80-90%
Moderate 70-80%
Severe < 70%
























Ideal body height for 1 year and above
Height in cm = age in years x 5 + 80
= 4 x 5 +80
= 100cm

Waterlow classification for stunting:
Actual height
X 100
Ideal height

= 109cm/ 100 cm x 100
= 109% - the patient is normal, not stunted

CLASSIFICATION
Normal 95%
Mild 90-95%
Moderate 80-90%
Severe < 80%

Body Mass Index:
BMI= weight in kg (kg)
Height
2
(m
2
)


Convert: 109 cm / 100 = 01.09 m
1.09 x 1.09 = 1.1881 m
2


BMI= 17.25 kg/ 1.1881 = 14.52





Regional Examination:
Integument
Inspection: The skin is moist, smooth with good skin turgor and fair in color. (-) pallor, (-) jaundice,
(-) erythema and (-) edema. There is no dryness. There are no primary lesions such as macules,
papules, nodules, plaques, vesicles, wheals and pustules.
Palpation: The skin is not warm, slightly cool to touch but with good capillary refill.
Head and Neck
Inspection: The hair is black in color and straight with even distribution. No presence of hair loss,
and scalp is devoid of any lumps, scales and flakes. The head is normocephalic, positioned in
center and in midline, with symmetrical facial features, and is devoid of any masses. The trachea
is in midline and the thyroid cartilage moves with deglutition.
Palpation: There in no presence of head tenderness. The thyroid gland is not palpable. There is
no enlargement of parotid or submandibular glands and cervical lymphadenopathy.

Eyes
The eyes are symmetrical. The pupils are equally round and react to both direct and
consensual light reflex. Visual field and extra ocular movements are all intact. There are no
nasolacrimal duct swelling, pink conjunctiva, no opacities in the lens, masses and discharge.

Ears, Nose, Throat
The external nose is symmetrical, aligned vertically with the midline and has no masses
and deformities. The external nares are equal in size and patent. The nasal septum is in the
midline.
The pinnas are mobile and devoid of masses, ulcerations and tenderness. The
periauricular areas likewise have no swelling or tenderness. Presence of impacted cerumen on
left ear.
The lips are symmetrical, pinkish, moist and free of any masses or ulcerations. Oral
mucosa and gums are pinkish. Tongue is pinkish red in color and is in the midline, no masses or
ulceration.

Chest and Lungs
Inspection: The Chest is symmetrical as well as the chest expansion with no signs of respiratory
distress such as use of accessory muscle. AP diameter is 1;1
Palpation: Tactile fremitus equal and thoracic expansion are equal
Percussion: Resonant
Auscultation: Normal breath sounds on all lung fields

Cardiovascular
Inspection: There is no precordial bulging.
Palpation: No heaves/ thrills were heard
Auscultation: The heart has irregular rhythm. S1 > S2 is heard at the apex, S2 > S1 is heard at
the base. No abdominal bruits or pulsatile masses were auscultated.

Abdomen
Inspection: The abdomen is scaphoid and symmetrical. There are no discoloration, scars, lesions,
visible veins, dilated veins, pulsations or peristalsis. Umbilicus is inverted.
Auscultation: Bowel sounds are normoactive at 14/min.
Palpation: Abdomen is soft and non-tender. There is no presence of bruit, friction rub,
organomegaly or ascites.
Special Maneuvers: No presence of Murphys sign, Fluid wave, no direct tenderness on all
quadrants, no Rovsings sign, cough sign, Psoas sign, Rebound tenderness or Obturator sign

Neurologic
Patients general behavior is normal and dressed appropriately according to age and
occasion. Stream of talk is slow and the patients mood is appropriate, seems shy but smiles
most of the time. Theres no presence of illusions, delusions, paranoia, misinterpretation
hypochondriasis and auditory/ visual hallucinations. Her intellectual capacity is average.
Patient is awake, conscious and coherent. Oriented to place and name.

Cranial Nerves
I intact
II normal pupillary size, equal, round and reactive to light
III, IV, VI (-) ptosis
V not assessed
VII (+) facial movements and good facial tone
VIII intact
IX, X intact
XI not assessed
XII intact

Motor System:
Inspection: General activity is intact. There is no tremors and involuntary movements.
Palpation: There is no atrophy and hypertrophy on muscle bulk. Body is symmetrical. There is no
joint misalignments and fasciculations. Muscle tone is not flaccid, spastic or rigid.

Sensory Testing: intact touch and pain sense, others not assessed
Cerebellar: not assessed
Meningeals: (-) Kernigs, (-) Brudzinkis (-) Passive Neck Fflexion
Higher cerebral functions: not assessed

CLINICAL ASSESSMENT

This is a 4 years old male from Dasmarias, Cavite, consulted for the third time in DLS-
UMC at around 2:30 pm with the chief complaint of epigastric pain.
Primary Impression:
Viral Gastroenteritis
Basis for the Diagnosis
o (+) acute diarrhea
o (+)Fever
o (+)Headache
o (+) Epigastric pain
Case Discussion:
This is a case of C.S., 4 years old, male, Filipino who presented mild epigastric pain with
loose bowel movement which is characterized by brown, watery, milky like with bubbles three
days prior to consultation. He was noted to be hot to touch and accompanied by nausea and mild
headache as verbalized by the patient as masakit lang. The patient didnt experience any
danger signs like intractable vomiting, blood in stool, poor feeding or decreases sensorium. The
patient shows no signs of dehydration like restlessness, lethargic, sunken eyes, drinks eagerly or
skin pinch goes back slowly.
The patients symptoms that will be given focus in this discussion are the epigastric pain
and loose bowel movement that started two days prior to consultation. Acute abdominal pain can
be divided into mild, moderate, severe and very severe. Mild abdominal pain which the patient
noted interferes minimally with activity or pain associated with a known benign cause such a viral
gastroenteritis. Moderate pain interferes minimally with activity or associated signs of bacterial
infection while severe pain is accompanied by alterations in mental status, or presence of signs of
moderate or severe dehydration. Very severe abdominal pain usually has signs of sepsis with
altered mental status or poor peripheral perfusion or hypotension or respiratory distress.
Diarrhea is best desribed as excessive loos of fluids and electrolytes in the stool. There is
also a passage of unusually loose/ watery stool, at least three times in 24 hours. Diarrhea in
children has four clinical types which includes: acute watery diarrhea, acute bloody diarrhea,
persistent diarrhea, chronic diarrhea and diarrhea with severe malnutrition. Acute watery diarrhea
can accompanied by dehydration and weigh loss while acute bloody diarrhea can be caused by
sepsis, malnutrition, dehydration and intestinal damage. Persistent diarrhea that usually lasts for
10-14 days can be due to malnutrition, serious non-intestinal infection and dehydration. Chronic
diarrhea lasts for more than 14 days and lastly, diarrhea with severe malnutrition can be
experienced because of vitamin and mineral deficiency, severe systemic infection, dehydration
and heart failure. The patients diarrhea started 2 days prior to consultation characterized by
watery stool thus the patient has Acute Watery Diarrhea with no dehydration. Clinical features of
dehydration are classified according to its severity and with regards to the patient, he has no
symptoms or signs of dehydration.

Clinical features of
dehydration acc. to
severity (WHO &
AAP)
Manifestations
No
dehydration
Mild
dehydration
Moderate
dehydration
Severe dehydration
Weight loss 0-2 % 3-5 % 6-9% >/= 10%
Mental status Normal Normal Irritable Normal to lethargic
to comatose
Thirst Normal to sl. Slightly increased Moderately Very thirsty or too
lethargic to indicate
Anterior fontanel Normal Normal Sunken Very sunken
Eyes Normal Normal Sunken Grossly sunken
Tears Present Present Absent to Absent
Mucous membranes Normal Sl. Dry Dry Parched
Respiration Normal Normal Deep, rapid Deep and rapid
Skin pinch Immediate Intermediate Slow Very slow
Radial pulse Normal Normal Rapid & weak Rapid, feeble
Heart rate Normal Normal Increased Inc. or dec. if sever
Systolic BP Normal Normal Normal Low/undetectable
Extremities Warm Warm Sl. Cool Cool, mottled,
acrocyanotic
Urine flow Normal Slightly reduced Reduced & dark < 1
ml/kg/hr
Anuria / severe
oliguria << 1
ml/kg/hr
Capillary refill Normal Normal 2 sec. > 3 sec.
Estimated fluid
deficit
</= 20 ml/kg 30 50 ml/kg 60 90 ml/kg >/= 100 ml/kg
Acute gastroenteritis is a common illness that affects persons of all ages worldwide.
Several enteric viruses are identified as common etiologic agents of acute gastroenteritis, this
includes Rotavirus, Adenovirus, Enterovirus, Astrovirus and Calicivirus. Acute gastroenteritis can
be caused by bacterial organisms and the most common culprit for acute gastroenteritis are
E.coli, Shigella, Salmonella, Campylobacter, Cholera and Giardia. Several features can help
differentiate gastroenteritis caused by virus from that caused by bacterial agents. However, the
distinction on clinical and epidemiologic parameters alone is mostly difficult, and laboratory tests
may be required to confirm the diagnosis.
Major risk factors for acute gastroenteritis are environmental contamination and
increased exposure to enteropathogens. The patients mother noted that they use the water from
their faucet which is from NAWASA as their drinking water. This may serve as a risk factor for the
baby since water can serve as a contaminant of different pathogens and given the age of the
patient, he is at risk of developing infections easily. Lack of exclusive or predominant
breastfeeding can be an additional risk factor in developing infection. Breastmilk contains ideal
proportion of fats, vitamins, sugar and water for infant development. It also contains
immunoglobuliins that will help protect against infectious disease caused by different pathogens.
The patient was not exclusively breastfed when he was still a baby and can be a factor in having
the gastroenteritis.



























Differential diagnosis
Giardasis
Is a major diarrheal disease found throughout the world. This can cause asymptomatic
colonization or acute or chronic diarrheal illness. The clinical signs and symptoms that was
present in the patient is presence of abdominal pain and diarrhea so this was ruled in. But the
stool characteristic in Giardasis is different from that of what the patient had experienced. In
Giardasis, the stool is malodorous and greasy. Based on the description of the patients mother,
his stool was watery brown and no peculiar smell.
Typhoid Fever
Is also known as enteric fever, the classic presentation of this disease that is present in the
patient is fever, abdominal pain and mild diarrhea. This was ruled out because the fever of the
Predisposing Factors
Age
Malnutrition
Predcipitating Factors
Contaminated
food and water
Ingestion of fecally
contaminated food and water
Direct invasion of the bowel
wall
Endotoxins are released and
cytotoxin elaboration
(Arachidonic acid,
metabolites, cytokines)
Stimulation of destruction of
mucosal lining of the bowel
Digestive and absorptive
malfunction
Excessive gas formation Increase peristaltic
movement
Secretion of fluid and
electrolytes in the intestinal
lumen
GI distention
MIld diarrhea (2-3 stools per
day)
Fever
patient is not constant and it didnt last long. Also theres no presence of salmon-colored rash in
the patients trunk.
Clostridium Difficile Colitis
This results from a disturbance of the normal bacterial flora of the colon, colonization by
C difficile, and the release of toxins that cause mucosal inflammation and damage. This was
considered as differential diagnosis due to the presence of the symptoms like abdominal pain,
nausea, fever and mild diarrhea. This cannot be ruled out due to the lack of diagnostic test given
but most cases of C difficile colitis has anorexia and malaise that the patient is lacking. Also, in
Giardiasis, the patient will experience flatulence, anorexia, weight loss, vomiting and urticaria.
Management:
Diagnostic

Diagnostic tests for acute gastroenteritis are mostly based on the patients history and physical
examination. But inorder to identify the pathogen responsible for the disease, stool exam will help
to know if there are any parasites in the stool and presence of blood. Immunoassay is not widely
used in the Philippines, but is done to identify the virus responsible for the patients condition.
Another simple laboratory test may be requested to identify if the patient has infection reflected by
WBC count, presence of anemia may be possible if the patient is bleeding. Serum electrolytes will
be needed to know if the patient has electrolyte imbalance due to dehydration caused by the
diarrhea and lastly, abdominal imaging studies might be helpful if the patients epigastric pain plus
fever has an unknown cause.
Therapeutic
There is no specific treatments for Acute Gastroenteritis, so the therapy is primarily
focused in prevention of dehydration, treat dehydration, prevent nutritional damage and reduce
the duration and severity of diarrhea and the occurrence of future episodes by giving
supplemental zinc. The condition is self-limited, and prescribing antibiotics as usual, do not
hasten improvement. Care is usually supportive and make sure that the patient is having
adequate nutrition and hydration. Bed rest is also recommended and increase oral fluid intake of
water. For the patient, treatment Plan A that includes home therapy to prevent dehydration and
prevent malnutrition is advised. Treatment plan A includes the following:
Give the child more fluids than usual to prevent dehydration
Give supplemental Zinc 10-20 mg everyday for 10-14 days
Continue to feed the child to prevent malnutrition
Take the child to the hospital or clinic if there are signs of dehydration or other
problems

References:
Bickley, L. S., Szilagyi, P. G., & Bates, B. (2009). Bates' guide to physical examination and
history taking. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins
Kasper, D. L., & Harrison, T. R. (2005). Harrison's principles of internal medicine. New York:
McGraw-Hill, Medical Pub. Division.
Kleigman, R.M., et al. Nelson Textbook of Pediatrics. 19th ed. Philadelphia: Saunders, 2011.
"Weight-for-age." WHO. N.p., n.d. Web. 26 May 2014.
WHO Protocol: Integrated Management of Childhood Illness (2008) The analytic review of the
Integrated Management of Childhood Illness strategy: final report/DFID[et al.]. 2003