CEBU DOCTORS’ UNIVERSITY HOSPITAL

DEPARTMENT OF PEDIATRICS
ENDORSEMENT

CLINICAL CLERK IN CHARGE:

Group 10 - Pinili, Grachelle Rhey

Intern Monitor:
Dr. Melisa Rosales

Submitted to:
Dr. Corazon Mendezona
Date and Time: July 25, 2023 4pm
Source: Mother
Reliability: 98%

A. General Data:
N.N., 8 years old, Filipino, born on December 17, 2014, in Japan, currently
residing in Horizon 101, Cebu City, came in at the CDUH for the first time.

B. Chief Complaint: diarrhea and vomiting

C. History of Present Illness:

16 hrs PTA, patient had an onset of 15 episodes of watery stool. The first episode
amounted to 1 cup and half a cup thereafter, characterized as yellowish with little
solid particles. Food eaten prior was street food, shrimps and ramen. Meds taken
were 2 tablets of seirogan which stopped the diarrhea. No fever, no abdominal
pain, no rashes.

11 hrs PTA, patient had an onset of 1 episode of vomiting. Vomitus characterized

as watery and yellowish in color. Non-stop vomiting until 10am with unrecalled
episodes. This was accompanied with headache. No meds taken. Food intake
was soup and pocari sweat at 1pm. No fever, no abdominal pain, no rashes, no
diarrhea.

1 hr PTA, patient had onset of epigastric pain with a pain scale of 5/10.
Persistence of symptoms prompted admission.

D. Prenatal History
The patient was born to a then 39-year old, G2P2 mother. First prenatal check-up
was 5 weeks at Women’s clinic with regular visits. Ultrasound and labs taken
included CBC, UA, FBS, HIV, and HBsAg, all unremarkable. Mother’s Blood type
was A+. Mother is a non-smoker, drinks alcoholic beverage occasionally, and has
no history of illicit drug use.

E. Natal History
The patient was delivered preterm with a birth rank of 2/2 via NSD, AS 8,9, BS 38
wks, BW 2800hrams. Patient stayed in the nursery for 5 and was discharged
without complications.

F. Postnatal History
a. Feeding History
The patient was mixed fed since birth. Semisolid foods introduced at 4 months
old.
 Growth and Development
i. Growth and Development
ii. GROSSMOTORSKILLS
1. Can jump rope or ride a bike
2. Can catch a ball with one hand

iii. FINE MOTORSKILLS

1. Can hold a pencil with 3 fingered grasp
2. Cutting neatly around shapes

iv. LANGUAGE SKILLS

1. Can read books

v. COGNITIVE SKILLS
1. Can complete instructions with 3 or more steps
2. Knows how to count by 2s

b. Immunization history
i. Patient had BCG and HepB given at birth. Unrecalled other
immunizations but complete as claimed in a private clinic.

G. Past Medical History

None

H. Family Medical History

Patient’s father is 55 years old, an cells office worker while her mother is 48
years old, a teacher both of whom are in good health. Heredofamilial diseases
are hypertension and asthma on mother’s side.

I. Social History
Patient lives with her family in the house of the patients own house, with good
electric and water supply, and regular garbage collection. Drinking water is
mineral water.

REVIEW OF SYSTEMS

No abnormalities noted.
 PHYSICAL EXAMINATION

General Survey
The patient is awake, alert, not in respiratory distress.

Vital signs
HR = 83 bpm
RR = 18 cpm
Temp = 36.4OC
O2= 100%

Anthropometric Measurements
Length = 124 cm (z-score: 0)
Weight = 18.5kg (z-score: -2)
BMI = 12kg/m²

GROWTH CHARTS

L: 93
Z score:

Wt: 9.5kgs
Z score: 3
BMI: 11kg/m2
z score: -3

Physical Exam
Skin:
Inspection: (-) jaundice, (-) rashes
Palpation: warm, moist with good skin turgor and mobility

HEENT
Head: Head is symmetric with no deformities.
Eyes: anicteric sclerae
Ears: No discharges and deformities noted
Nose: Septum is in the midline, (-) discharge, (-) bleeding, (-) alar flaring
Mouth: moist oral mucosa, dry lips

NECK
No cervical lymphadenopathies noted.

Chest and Lungs

Inspection: Symmetric chest with no deformities. Normal rate and depth of breathing. Equal
chest expansion noted. No intercostal and subcostal retractions.
Palpation: No tenderness noted.
Auscultation: clear breath sounds

Cardiovascular System
Inspection: No cyanosis noted
Palpation: (-) thrills
Auscultation: Distinct heart sounds, Normal sinus dysrhythmia, (-) murmurs

Abdomen
Inspection: (-) lesions, (-) umbilical hernias, (-) gross deformities
Auscultation: Normoactive bowel sounds
Percussion: tympanitic,
Palpation: soft, tender on the epigastric area, (-) palpable masses.

Genitourinary System
Labia majora and minora and vaginal orifice is present. Urethral meatus located below the
clitoris. No masses in the inguinal area.

Extremities
Warm extremities with strong peripheral pulses. CRT <2 seconds.

Neurologic Examination
Motor Tone: Normal
Sensory: (+) arousable by touching
Cranial Nerves:
CN I: not assessed
CN II, III: (+) blink in response to light
CN V Motor: (+) rooting reflex, (+) sucking reflex
CN VII: symmetric face when crying
Clinical Impression
Acute Gastroenteritis with Moderate Dehydration

DIFFERENTIAL DIAGNOSIS
CONDITION RULE IN RULE OUT

1. Inflammatory Bowel Diarrhea Blood in stool

Disease Abdominal pain Weight loss
Fever

2. Food Allergy Diarrhea coughing

Abdominal pain Wheezing
Angioedema

3. Gastritis Diarrhea Abdominal bloating

Abdominal pain
Vomiting

4.

Basis:
● Px is 8 years old - this age is prone to viral infection
● 15 episodes of vomiting
● Epigastric pain
● Vomiting
● Headache
● Previously ingested food was from street food

Diagnostic Management
○ CBC
○ UA
○ Serum electrolytes
○ Stool exam

Therapeutic Management
- Ranitidine 20mg IVTT q8h
- Zinc sulfate syrup 5ml once a day
- Maintenance fluid of 1425ml ( 1000 + 425 = 1425ml)
- D5LR 1L x 1
- D5LR 500ml x 1
- Rate: 60cc/hr