PEDIA INTEGRATION 2

GI CASE

General Data

Patient’s Name K.G.

Birthday August 22, 2021
Age 1 year and 1 month
Birthplace Bacolod City
Sex Male
Religion Roman Catholic
Nationality Filipino
Residential Address Hda. Elsa, Providence, Bacolod City
Name of Informant Mae Jis Garcia, 24
Relationship of Informant Mother
Occupation of Informant Housewife
Reliability of Informant 95%
Date of Admission October 7, 2022
Time of Admission 7: 00 PM PST

Chief Complaint Vomiting

History of Present Illness

2 days PTA, patient presented with sudden multiple episodes of non-foul, non-fishy,
loose watery greenish stool with associated abdominal distention, the mother changed diapers
four times that day.

1 day PTA, patient became weak, malaise and poor feeding. Multiple episodes of loose,
watery, greenish stool were still present. The mother sought folk medicine for the patient but
with no relief.

On the day of admission, the patient still has body weakness, malaise, non febrile loose
watery greenish stool, and sunken eyeballs. Vomitus was non-bilious, non-bloody, and was
observed postprandially. The patient vomits five times a day with two to three cups. He was
given 5mL suspension of Erceflora by the mother after searching on the internet but no relief
was noted. The family eventually decided to bring the patient to the ER.
Review of Systems
General
(+) weight loss
(+) fatigue
(+) weakness
(+) trouble sleeping
Skin
(+) warm to touch
(+) dryness

HEENT
(-) head injury
(+) sunken eyeballs
(-) eye discharge
(-) ear drainage
(-) nasal discharge
(-) alar flaring
(+) dry oral mucosa

Respiratory
(-) cough
(+) tachypnea

Cardiovascular
(-) heart trouble
(-) heart murmur
(-) chest pain

Gastrointestinal
(+) appetite change
(+) food intolerance
(+) change in bowel habits
(-) jaundice
(-) liver trouble

Genitourinary
(+) oliguria
(-) testicular pain
(-) testicular lesion

Musculoskeletal
(+) weakness

Neurologic
(-) seizure

Endocrine
(+) excessive thirst
Birth and Maternal History

Gestational History

The patient was born to a 24 year old G1 P1 (1-0-0-1) mother at 40-41 weeks. The
mother had regular prenatal check-ups which started on the first trimester until her term, in
Bacolod City Health. She was prescribed intrapartum supplements such as Iron and Folic Acid
and was able to receive 2 doses of Covid-19 vaccination before conceiving. She was also given
tetanus vaccine during the first trimester and immediately after birth. The mother denies taking
medications, smoking, alcohol consumption, and use of illicit drugs. Last menstrual period of the
mother was in December 2020.

Birth History

K.G was delivered full term by normal spontaneous vaginal delivery in cephalic
presentation at Bacolod City Lying-In Center by a midwife. Patient was put in the mothers chest
after birth and was breastfed immediately. Fetal distress was not noted.

Neonatal History

K.G was born with a good cry and pinkish color of skin with an APGAR Score of 9,
weighing 3.5kg. In newborn screening all except G6PD deficiency was unremarkable.

Past Medical History

(-) Asthma
(-) Chicken Pox
(-) Ear Infection
(-) Epistaxis
(-) Measles
(-) Mumps
(-) Poliomyelitis
(-) Primary Complex
(-) Rheumatic Fever
(-) Rubella
(-) Tonsillitis
(-) Whooping cough
(-) Hospitalizations
(-) Previous Surgeries
(-) Injuries
(-) Allergies

Family History (To Follow - Insignificant Findings)

Personal History

The patient is an only child. The father works as a construction worker while the mother was a
call center agent and eventually resigned and became a plain housewife. They live in a concrete house.
There are only 3 members in the house. The patient would frequently play outside the house; picking up
objects from the soil, such as rocks.

The child usually has a good sleep starting at 8 or 9 in the evening and wakes up at 4 in the
morning. Until recently disrupted by sudden loose bowel movement.

Developmental and Behavioral History

Gross motor

● Can move and hold head in all directions, can sit, stand, and walk without
assistance, can pick up small objects from the floor with thumb and forefinger,
can kick and throw a ball

Personal and Social

● Can say “yes and no”.

● Interacts well with parents and grandparents

Reflexes:

● Moro, Startle, and Sucking Reflexes intact

Nutritional History

Dietary patterns:

● Usually drinks 2 cups of mineral water, and 2 to 3 bottles of milk (Bonakid) per day. The
mother frequently changes diapers with an average of 4 to 5 due to the child's urination.
Has the usual meals such as soup/stew, rice, and biscuits.

Environmental History

The area of residence was described to be of an urban environment. There are high levels of air
pollution and smoke in the area and water supply is taken from BACIWA, while the family’s drinking
water supply is mineral water bought in a water refilling station. The house and the play area is mainly
surrounded by soil and garbage littered about. The family has/owns pets - cat and dog. Garbage is not
properly collected and tends to accumulate around their residence.
Immunization History

Vaccine Route Dose/s

BCG (Bacillus Calmette-Guérin) Intradermal 1

Hepatitis B
Intramuscular 1

Pentavalent vaccine
(DPT-Hep B- HiB) Intramuscular 3

Oral Polio Vaccine (OPV) Oral 3

Pneumococcal conjugate vaccine Intramuscular 3

(PCV13 or PCV10)

Inactivated Polio Vaccine (IPV) Intramuscular 1

Measles, Mumps, Rubella (MMR) Subcutaneous 2

vaccine
 PHYSICAL EXAMINATION

GENERAL SURVEY:
Upon admission, the patient was irritable and was in cardiopulmonary distress. The patient
appeared well-developed for their age.

VITAL SIGNS:
Patient Normal Values Correlation

Blood pressure 90/60 90-105/55-70 mmHg Normal

Pulse rate 132 bpm 70-110 bpm Tachycardic

Respiratory rate 31 bpm 20-30 bpm Tachypnic

Temperature 36.5 ℃ 36.6-37.9 ℃ Hypothermic

O2 saturation 98% >95% Normal

ANTHROPOMETRICS:

Weight: 9 kgs
Height: Pending
BMI:
HEENT:

Eyes:
(+) sunken eyeballs
Anicteric sclera

Nose:
No alar flaring

Mouth:
(+) Dry oral mucosa

CHEST AND LUNGS

No retractions
Clear breath sounds

CARDIOVASCULAR
Adynamic precordium

ABDOMEN
Soft, distended abdomen

SKIN AND EXTREMITIES

Full pulses
CRT: <2 secs
Warm extremities
 NEUROLOGIC EXAMINATION
(Done at 3rd day of admission)
LEVEL OF ALERTNESS:
Patient was asleep and comfortable.

GLASGOW COMA SCALE:

Patient Score

Eye Opening Spontaneous 4

Verbalization Smiles, fixes, follows 5

Motor Obeys 6

Total Score 15

CRANIAL NERVE EXAMINATION:

Cranial Nerve/s Patient

II Optic nerve Patient was able to recognize their mother's

face and was able to track objects.

III, IV, VI Oculomotor, Trochlear, Abducens No nystagmus noted.

V Trigeminal Symmetrical grimace

VII Facial Face was symmetrical

VIII Vestibulocochlear Respond to mother’s voice. The patient turns

toward the sound.

IX, X Glossopharyngeal, Vagus Coordinated swallowing was noted.

XI Spinal Accessory The patient was able to turn their head against
resistance

XII Hypoglossal Tongue was midline, with no signs of atrophy

MOTOR DEVELOPMENT:

Motor Strength Patient exhibited spontaneous Good muscle strength

movement. The patient was
able to move despite resistance
exerted by mother.
 INITIAL LABORATORIES

CBC
HCT: 0.27
HGB: 83
WBC: 6.2
S: 72
L: 24
M: 6
PLT: 330

CHEM:
Na: 125.4
K: 2.6

STOOL:
Color: Green
Consistency: Watery
WBC: 3-5
RBC: 0-1
Bacillary form: Many
E. histolytica (cyst): 0-1
E. histolytica (trophozoite): 1-2
E. coli (cyst): 0-1

URINALYSIS:
*Px did not submit