A.

BIOGRAPHIC DATA

Name: Patient “X” Address: Purok 5, Brgy. Langub, Davao

City
Sex: Female
Civil Status: Single
Age: 8 y/o
Occupation: Student
Weight: 22.5kg
Informant: Mother of the patient
Height: 122 cm
Chief Complaint: Abdominal pain and
Nationality: Filipino
Loose bowel movement
Language: Bisaya

B. CLINICAL/ADMITTING DATA

Date of Admission: September 1, 2020

Informant: Mother of the patient

Chief Complaint: Abdominal pain and loose bowel movement

C. HERTORY OF PRESENT ILLNESS

4 days prior to admission, patient experienced abdominal pain in the right and left lower
quadrant. There was associated with nausea, vomiting, intermittent fever and loose bowel
movement, no consultation done, but herbal medicine was given to the patient at home. Until 1
day prior to admission patient was positive of several episodes of LBM, 4 times a day, yellowish
in color, foul smelling, watery, no mucoid, no blood streaked and positive fever again no
consultation done. Upon admission, the patient experienced abdominal pain and anxious at the
emergency room. With admitting vital signs of BP- 90/60 mmHg, CR- 110bpm, RR- 22cpm,
Temp- 37.9˚C

D. PAST MEDICAL HERTORY

According to the patient’s mother, the patient has her complete immunizations. She seldom take
vitamin and supplements, thus, she has a slim built. No allergies to food and drugs noted. The
patient was first hospitalized due to cough and colds and the latest was due to abdominal pain
and loose bowel movement.

E. FAMILY HEALTH HERTORY

According to the patient’s mother, their family have hertory of Hypertension,Diabetes mellitus,
Bronchial Asthma and Cancer. Hypertension is evident onthe patient’s grandfather and uncle,
while Cancer is evident on the patient’saunt.

F. PERSONAL, FAMILY AND SOCIO-ECONOMIC

Patient X is the youngest of the 2 children in the family. The mother was a house wife while the
father was a carpenter.

G. REVIEW OF SYSTEMS
I. Constitutional: (-) Weight Change, (+) Fever, (+) Chills, (-) Night Sweats, (+) Fatigue,
(-) Malaise
II. ENT/Mouth: (-) Hearing Changes, (-) Ear Pain, (-) Nasal Congestion, (-) Sinus Pain, (-)
Hoarseness, (-) sore throat, (-) Rhinorrhea, No Swallowing Difficulty
III. Eyes: (-) Eye Pain, (-) Swelling, (-) Redness, (-) Foreign Body, (-) Discharge, (-) Vision
Changes
IV. Cardiovascular: (-) Chest Pain, (-) SOB, (-) PND, (-) Dyspnea on Exertion, (-)
Orthopnea, (-) Claudication, (-) Edema, (-) Palpitations
V. Respiratory: (-) Cough, (-) Sputum, (-) Wheezing, (-) Smoke Exposure, (-) Dyspnea
 VI. Gastrointestinal: (+) Nausea, (+) Vomiting, (+) Diarrhea, (-) Constipation, (+) Pain, (-)
Heartburn, (-) Anorexia, (-) Dysphagia, (-) Hematochezia, (-) Melena, (-) Flatulence, (-)
Jaundice
VII. Genitourinary: (-) Dysmenorrhea, (-) DUB, (-) Dyspareunia, (-) Dysuria, (-) Urinary
Frequency, (-) Hematuria, (-) Urinary Incontinence, (-) Urgency, (-) Flank Pain, (-)
Urinary Flow Changes, (-) Hesitancy
VIII. Musculoskeletal: (-) Arthralgias, (-) Myalgias, (-) Joint Swelling, (-) Joint Stiffness, (-)
Back Pain, (-) Neck Pain, (-) Injury History
IX. Skin: (-) Skin Lesions, (-) Pruritis, (-) Hair Changes, (-) Breast/Skin Changes, (-) Nipple
Discharge
X. Neurologic: (+) Weakness, (-) Numbness, (-) Paresthesias, (-) Loss of Consciousness,
(-) Syncope, (-) Dizziness, (-) Headache, (-) Coordination Changes, (-) Recent Falls
XI. Psych: (+) Anxiety/Panic, (-) Depression, (-) Insomnia, (-) Personality Changes, (-)
Delusions, (-) Rumination, (-) Social Issues, (-) Memory Changes, (-) Violence/Abuse
Hx., (-) Eating Concerns
XII. Heme/Lymph: (-) Bruising, (-) Bleeding, (-) Transfusions History, (-) Lymphadenopathy
XIII. Endocrine: (-) Polyuria, (-) Polydipsia, (+) Temperature Intolerance

H. PHYSICAL ASSESSMENT
General Assessment
Physical assessment of Patient “X” was done today, September 1, 2019 at Davao city.
She is irritable and anxious. She displayed a guarding behavior due to abdominal pain.
Her current weight is 22.5kg, current height is 122 cm which is a BMI of 6.9 (severe
malnutrition)
 I. Skin, Hair, and Nails
Skin

INSPECTION: Patient X has a brown skin complexion.

PALPATION: Her skin is dry, soft, and warm to touch but has poor skin turgor.

Hair

INSPECTION: Patient’s hair is black in color. No foul odor and dandruff was noted.
Her hair is evenly distributed.

II. Head, Face, Neck, and Regional Lymph Nodes

Head

INSPECTION: Her head is normocephalic and symmetrical. No lesions noted

PALPATION: Upon palpation, there were no tenderness noted.

Face

INSPECTION: Patient’s face is symmetric and appeared dry.

PALPATION: There were no tenderness and lumps noted upon palpation.
III. Eyes, Eyebrows, and Eyelashes
INSPECTION: Patient “X’s eyebrows are evenly distributed. They are symmetrically
aligned and has equal movement. Sunken eyeballs were noted. No ptosis, ectropion and
entropion were observed. Furthermore, her bulbar and palpebral conjunctiva are pale. The
pupils are black that is equally round and reactive to light accommodation.

Neck

INSPECTION: The patient’s neck is in midline. Neck veins were not distended and no
irregular pulsating was observed.
PALPATION: No masses and enlargement of the facial lymph nodes were noted, and
her trachea is in the midline on her neck.
IV. Ears
 INSPECTION: Patient’s ears are of equal size bilaterally. No foreign bodies, swelling,
masses, lesions and discharges noted. Patient was able to hear spoken words bilaterally.

V. Nose and Sinuses, Mouth and Throat

Nose and Sinuses

INSPECTION: Patient “X”’s nose is in the midline of the face. There were no
deformities, bleeding, masses and discharges noted upon inspection. The patient has
patent nares and can distinguish between pleasant and foul odors.

Mouth

INSPECTION: Patient’s lips were pale and dry. The mucous membrane is dry and
pale. The tongue is slightly pale in color and dry, the buccal mucusa is also dry

Thorax and Lungs

INSPECTION: Patient “X”’s respiration is normal with 22 breaths per cycle. Her
respirations is not labored and he does not use any accessory muscle when breathing.
Moreover, her breathing is rhythmic, quiet, and effortless.
PALPATION: The chest wall is intact with no tenderness and masses when palpated.
PERCUSSION: The lung fields are resonant during percussion in the anterior left and
right midclavicular line and midaxillary line.
AUSCULATATION: No adventitious sound were heard on both lung lobes during
auscultation.
VI. Heart and Neck Veins
INSPECTION: Upon inspection, the patient’s heart and neck veins show negative
visible pulsation on the aortic and pulmonic areas. Also, the neck has no noticeable
jugular vein distention.
PALPATION: Her pulse rate is 110 beats per minute.
PERCUSSION: Percussion of heart border reveals heart is still normal in size
AUSCULTATION: Apical pulse shows a heart rate of 110 beats per minute with no
murmur noted.
 VII. Abdomen
INSPECTION: The patient’s abdomen is flat in shape.

AUSCULTATION: There were presence of hyperactive bowel sounds on all four

quadrants.

PALPATION: Umbilicus in the midline. Tenderness on both lower quadrant is noted

upon palpation.

VIII. Musculoskeletal system

INSPECTION: Patient “X” joints and muscles are symmetric with complete but weak
range of motion on both extremities. Muscle weakness was also observed on both
extremities but without crepitation observed.

IX. Genito-Urinary Assessment

No abnormalities found
I. SALIENT FEATURES
- 8 y/o Female
SIGNS AND SYMPTOMS
A. Diarrhea
- Consistency - watery
- Color - yellowish
- Odor – present/ foul smelling odor
- Frequency – 3 times a day (100-200 ml per elimination)
B. Vomiting
- 2 times a day (200 ml)
C. Tenesmus
D. Polydipsia
E. Poor skin turgor
F. Warmth to touch/ fever 37.9
G. Dry buccal Mucosa
H. Dry tongue and lips
I. Abdominal Pain in both lower quadrants
J. Hyper active bowel movement
K. Tympanitic
L. Polidypsia
J. OTHER PROBLEM LIST
- Source of water (well)
- Hand Hygiene with soap

K. DIFFERENTIAL DIAGNOSIS

DISEASES RULE IN RULE OUT

Acute Gastro Enteritis Vomiting
Abdominal cramps and
pain
Non-bloody diarrhea
Dehydration
Dry mucousal membrane
Poor skin turgor
Hyper active bowel sounds
Polydipsia
Shigella Diarrhea Bloody stool
Fever
Stomach pain
Tenesmus
Salmonella Fever Blood in the stool
Diarrhea
Vomiting
Stomach pain
Typoid Fever Diarrhea Loss of appetite
Stomach pain Headache
Dehydration Cough
Dry mucousal membrane Constipation
Poor skin turgor
 Hyper active bowel sounds
Polydipsia
Cholera Dry Mucous Membrane Rice Watery Stool
Diarrhea Rapid Heart Rate
Fever
Thirst
Dehydration
Dry mucousal membrane
Poor skin turgor
Hyper active bowel sounds
Polydipsia
Stomach pain

L. LEARNING OBJECTIVES
In completing this case presentation, the group should be able to:

 Grasp the anatomy of the gastrointestinal system

 Apprehend the histologic component of the gastrointestinal system
 Understand the physiology of the gastrointestinal system
 Realize the importance of rehydration in the human body
 Figure out the role of electrolytes in the human body
 Differentiate the types of diarrhea
 Learn the steps and perform dehydration assessment and interventions
 Master the different preventive ways of diarrhea and the importance of
health teachings for community involvement