Hospital Serdag

Name : Qualish Ezra Gender-Male

RW :
SD01029361 Informat :
Dad

Age 478-
:

Chief
Complaint

I
ragged clark the father of Qualish Ezra 4
yould presented to the ED
boy
a who
to ,

chief of admission .
complaint adopac
vomiting
alw
of Hosp Srig says
to
.
w . a
prior
,
Ihr after weal

web) F
stays
Patent until last
vomiting
well started in the
previously pt
evening
the
was
go ,

He vomited once I the vovitus was non-billows with no blood stairs ,

projective vorit , which
content was
said food They food looked his
by
untained
J during
- . he ate prior len which was

experienced tabdominal
(fried
yg) He pain alongside vanity
w X .
cirit
father 3 also
.

rice .

An-Nor in
The pt was to Klinik Chang where he was
30] given
I
subset
helped relief the and
pain.
vomiting
antiemetics and atspasmodics .
This biomind

&
following
The with
jys appeared be
syupters.
well
it
receiving
to no
,

His bowel habits were normal (once .

a dy)
projecte

and episode off His

Saturday vomiting
On ,
the patent expo his poets
could not determit the character of the vorites & he vorit in the car at

of ould not determine

night .
It also omplained abdominal
pain
but his parents
actual site of pain
They noted spike temperature
following vomiting
in his
body
the
.
. a

It was
bright yae
to Ninik An-Nether where he was Par
,
given
aticnetics and at spasmodics
.

PTA) 2 of
190g
mother
or have episodes
send y
continued to
,
pt
.

liquid wetet after each weal (lunch d dincel .

non-billing projective varity
with

of porridge meal de
spoorfulls
each
2-3 This was
patent
only
The a) a
.
-

X It eral intche)
cuplained of LOAs
aboo left pain
-
s

-]
in
which pt he waget able
pain
excruciating
the as

to all
upright
~
interrittent d
The pain thinghout the but
J
was
.

slightly
worked of
the The par was reviewed if the pt
vouity
.
as
lying
~
down
Besides that rout have fact the
throughout
to
pet
.

.
,

· His recorded
temp wa .
17.9% Pare
helped
] reporting
· .

relief the fur .

His father also stated that
pt appeared to

be however dified pallor of deyorator

lethagic signs
.
he
f I
,

very
GM: runs up and down
FM: hold pencil with good control. copies cross
Speech: able to name 4 colours
Sociall brushes teeth, dresses independently
General Inspection
Patient was well, alert, conscious and active. He was not pain or any respiratory
distress. There was no branula attached to the hand. His hydration status was fair.

BP 134/78
PR 110
RR 18
SpO2 98% under RA
Т 36.7

Growth Chart = length-for-age on the 95th percentile, weight-for-age on the

95th percentile. both are normal

Peripheral Examination

Both palms were warm and moist. There were no visible signs of finger
clubbing, peripheral cyanosis, or rashes. CRT was < 2s. BCG scar was
noted over the left deltoid.

There was no conjunctival pallor or scleral jaundice of the face. No signs of

pallor. For the mouth, the tongue was not coated and no signs of central
cyanosis with good oral hygiene.

Abdominal examination

Upon inspection, the abdomen moves symmetrically with each respiration. It is not distended and the
umbilical is centrally located and flat. There is no scar, skin discoloration, and visiblemass noted. Upon
palpation, the abdomen was soft, non tender and no rebound tenderness. No hepatosplenomegaly.
Kidneys are not ballotable and there was no costovertebral tenderness noted. Shifting dullness was not
done due to no abdominal distension. Upon auscultation, bowel sounds are heard at the normal
intensity with no aortic or renal bruits. There is no pedal edema.

Respiratory examination

Upon inspection, the chest moved symmetrical with inspirations with no scars or
deformities. Upon auscultation, there were equal air entry bilaterally with vesicular
breath sounds with no added sounds heard. Percussion resonated in all areas.

Cardiovascular examination

Dual rhythm no murmur heard.

 1x
&
-

Investigation
1. FBC
- to detect any bacterial infections evidenced by leukocytosis neutrophilia, viral infections
evidenced by lymphocytosis
- Platelet level as indicative for reaction to infection predominantly for dengue should be
thrombocytopenia in critical phase and thrombocytosis in febrile and recovery phase

2. Renal profile
- Urea and creatinine for dehydration status and acute kidney injury status in case of
dehydration &
- For detection of electrolyte imbalance

3. CRP
- For ongoing acute inflammation
Sp .

granity
4. Stool culture & sensitivity

-
- For rotavirus culture which is the common organism for AGE
Lubungs
-
beaches turbed
/sedy
Furozia
appearance
-

W
5 vie FEmE-mcroscopic
&
.

protnie
pyara

ho Y
sir
6 .
Rece uss
& interstea

X MR1 -
too expensive !

Mx
L

• Rehydration as for viral gastroenteritis.

• Antibiotics are not indicated, as the duration of
symptoms is not
altered and may increase chronic carrier status, unless
there is high risk of disseminated disease, presence of
artificial implants (e.g. V-P shunt), severe colitis, severe
systemic illness, age <6mths, enteric fever, cholera or E.
coli 0157. Most organisms are sensitive to ampicillin, co-
trimoxazole, or third generation cephalosporins.
• Consider:
• erythromycin if Campylobacter;
• oral vancomycin or metronidazole if Clostridium difficile
(causes
pseudomembranous colitis).

Intussusception =
u/S

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