Informant/s: Mother Date: September 23, 2019

Reliability: 85%

K.P., 3-year-old, female, Filipino, Roman Catholic born on February 11, 2016 currently residing in Carcar
City, Cebu, was admitted for the first time at University of Cebu – Medical Center (UCMed) on September
22, 2019 due to diarrhea and vomiting

Chief complaint: diarrhea and vomiting

Past Medical History

Prenatal History

Mother’s age was 33 years old at the time of pregnancy with an OB score of G2P1(1001). Blood type is B+.
No history of caesarean section. Exact age of gestation on first prenatal check-up at Chong Hua Hospital,
Mandaue, was unrecalled but she claims it was on the first month of pregnancy. She followed a regular
schedule of prenatal visits. Immunization received included 2 doses of tetanus toxoid vaccine given one
month apart at unrecalled AOG. She claims she had a regular intake of Iron, Folate, Calcium with
unrecalled doses, up to delivery with good compliance. She is asthmatic, nonhypertensive and
nondiabetic. Non-alcoholic beverage drinker. Nonsmoker. She was diagnosed with urinary tract infection
at about 12 weeks of gestation and was given unrecalled antibiotics. On the third trimester, she was
diagnosed with pneumonia and was admitted at the hospital for 1 week. Medication recalled includes
cefuroxime. Urinary tract infection recurred during term of pregnancy which persisted until delivery. Prior
to delivery, decreased fetal heart rate was observed prompting amniotomy to induce labor. No history of
abnormal bleeding during pregnancy. No history of surgical operations. No records of psychiatric
evaluation.

Natal History

K.P. was born at an unspecified weeks of gestation but mother, with an OB score of G2P2(2002), claimed
that she delivered her daughter at full term by normal spontaneous vaginal delivery on February 11, 2016
at University of Cebu – Medical Center. Good cry was noted immediately after delivery. No jaundice. No
cyanosis. No birth complications. Birth weight was 5 lbs, 8oz. Birth length unrecalled. Apgar and Ballard
scores were also unrecalled. Eye ointment, Hepatitis B vaccine, BCG and vitamin K were all given after
birth.

Postnatal History

No jaundice and cyanosis were noted after birth. Newborn screening was done. Blood type is B+. Due to
the urinary tract infection of the mother during delivery, K.P. stayed for 1 week at the Neonatal Intensive
Care Unit (NICU) at UCMed given with antibiotic Amikacin. Three days after birth, mother noted noisy
breathing from the infant. The attending physician gave the diagnosis of upper respiratory tract infection.
Following hospital discharge, K.P. was referred to a specialist in Cebu Doctor’s University Hospital (CDUH)
and finally diagnosed with laryngomalacia which was expected to resolve at the age of 18 months. At one
month old, patient was admitted for 1 week at CDUH due to fever and projectile vomiting and was given
with unrecalled antibiotics. Gastroesophageal reflux disease (GERD) was confirmed with physician’s
advice of upright positioning every after meals for 30 minutes. Mother claimed patient received complete
immunization from Department of Health, Region VII, Cebu and from a local health center. Breastfeeding
was only achieved during the first few weeks after birth. Milk formula was then given thereafter until four
months which was followed with semi-solid foods. Solid food was started after six months of age. Patient’s
social smile developed beyond 2 months. She uttered the first word “mama” at 9 months old. At 1 year
old, mother noticed K.P. does not turn head when name is called. She started walking only at 2 years old.
She was referred to a pediatrician and was diagnosed of Developmental Delay. Therapy with 2 sessions
per week was advised. Mother also noted that patient frequently drools which started at 1 year old and
persisted until now which is said to be related to GERD. Lansoprazole (Prevacid) was the medication
prescribed. Patient is non-asthmatic. Patient is allergic to chicken, chocolates and crustaceans. No history
of surgical operations.

Family History

Heredofamilial diseases include hypertension from both maternal and paternal side. Bronchial asthma is
also common in the maternal side of the family. Mother of the patient is 37 years, previously worked as a
nurse at South General Hospital, now a housewife. She has bronchial asthma and is allergic to chicken and
crustaceans. Father of the patient, a seaman, is 40 years old and is in good health condition. Patient is the
second child. Her two other siblings, one male, 11 years old and one female, 2 years old are all healthy.

Personal and Social History

Pat]ient lives with six other people in their own house in Carcar City, Cebu. She grew in an extended family
with her grandparents, mother, two siblings and her nanny. No pet animals. Mother usually prepares the
food during the day and sometimes buys ready-cooked foods for dinner. Daily diet of the patient mostly
includes biscuits, bread, rice, fish and milk. She is a picky-eater and does not eat vegetables. The family
drinks purified drinking water at home supplied from a water-refilling station. Patient is allergic to chicken,
chocolate and crustaceans

History of Present Illness

One day prior to admission, patient had three episodes of loose bowel movement with stool characterized
as watery, greenish in color which drips spontaneously through her legs amounting to about 1 cup per
episode. This was associated with fever recorded as 38oC and two episodes of vomiting of mostly saliva
and previously ingested food, whitish in color. Mother recalled that two days prior to the onset of the
symptoms, a ready-cooked pork meat called “humba” was eaten by the patient and the nanny. Nanny
claimed the meat tasted bad to which she developed abdominal pain that resolved the following day.
Mother suspected this was also maybe the cause of her child’s symptoms.

Eight hours prior to admission, patient had another 2 episodes of bowel movement with the same
character of stool as before. She was immediately brought to South General Hospital. Temperature was
39oC. Patient had no urine output nor bowel movement thus urinalysis and stool exam were not done.

Two hours prior to admission, patient was transferred to University of Cebu – Medical Center. On the way
to the hospital, patient had 3 episodes of vomiting with vomitus consisting mostly of saliva. Patient was
noted to be irritable. Upon arrival to the hospital, she was then admitted for diarrhea and vomiting.
Physical Examination

General Survey: Examined an awake, conscious, irritable patient with attached IVF, not in respiratory
distress with the following vital signs:

Temperature: 36.7oC Height: 91 cm

Blood pressure: mmHg Weight: 12 kg
Pulse rate: 110 bpm SpO2: 99 %
Respiratory rate: 19 cpm BMI: 14.5 kg/m2, 10th percentile, normal

Skin: Good mobility and turgor, pink skin, fair complexion, pink nail beds, no lesions
HEENT:
Head: Normocephalic
Eyes: equal, non-sunken, anicteric sclerae, pink palpebral conjunctivae
Ears: normal pinna, patent ear canal, no discharges nor swelling
Nose: patent nares, no discharges, no alar flaring
Mouth and Throat: pink moist lips and buccal mucosa, tongue midline, no pharyngeal and tonsillar
exudates
Neck: trachea at midline, no lymphadenopathy
Chest and Lungs: symmetric chest expansion, clear vesicular breath sounds
Cardiovascular: distinct S1 and S2, regular rate and rhythm, no murmur
Abdomen:
GUT:
Extremities: strong peripheral pulses, no edema, no cyanosis, CRT <2 sec
Musculoskeletal: no body deformities, no muscle atrophy

Neuwrologic Exam:
Cerebral: patient is awake, active and coherent
Cerebellar: well-coordinated movements, normal gait
Cranial nerves:
I – not tested
II – Bilateral blinking of eyes
III, IV, VI – full range of extraocular muscles
V – (+) corneal reflex
VII – symmetric facial expressions
VIII – follows source of sound
IX, X – able to swallow
XI – able to shrug shoulders
XII – tongue midline
Sensory: able to sense pain and vibration
Motor: spontaneous movement in all extremities, good tone, no atrophy
Reflex: draw normal stickman
FORMULATION
PRIMARY IMPRESSION: Acute Gastroenteritis with Some Dehydration

A 3-year-old presented with two to three episodes of diarrhea or passage of loose or watery stools and
vomiting, associated with abdominal pain and fever in which temperature ranged from 38-39oC. Patient
was also irritable during the onset of symptoms until admission. Based on the presenting symptoms, Acute
Gastroenteritis with Some Dehydration is considered as my primary impression.

According to Nelson’s Textbook of Pediatrics, 20th edition, the most common clinical manifestations of
gastrointestinal tract infection in children include diarrhea, abdominal cramps and vomiting. Risk factors
of the patient include crowding in the house (7 people) and eating of possibly contaminated foods.
According to a study, lack of exclusive breastfeeding (0-5 mos) also increases rate of morbidity and
mortality related to diarrhea. During diarrhea, there is an increased loss of water and electrolytes in the
liquid stool thus the degree of dehydration must be evaluated. Dehydration was assessed based on the
category stated in the World Health Organization’s (WHO) Manual for the Treatment of Diarrhea in which
a restless, irritable child is categorized as Category B or Some Dehydration. A core temperature of more
than 38.5oC, according to Nelson’s Textbook of Pediatrics, 20th ed, highly suggests a bacterial infection.
Fever may be caused by other types of infection or may arise depending on the severity of dehydration,
thus viral or parasitic pathogens must also be considered.

DIFFERENTIAL DIAGNOSES

Most gastrointestinal infections in children are caused by foodborne etiologic agents thus the
following are considered:

1. Rotavirus infection has an incubation period of 1-3 days commonly associated with vomiting,
watery diarrhea and low-grade fever. Commonly associated foods include fecally contaminated
foods and ready-to-eat foods touched by infected food workers. This etiologic agent is also the
most common viral cause of diarrhea in 24-59 months old patients.
2. Enterotoxigenic Escherichia coli (ETEC) are the major cause of acute watery diarrhea in children
and adults in developing countries, especially during the warm and wet season. Incubation period
is 1-3 days. Symptoms include watery diarrhea, abdominal cramps and some vomiting. Associated
foods include water or food contaminated with human feces.
3. Entamoeba histolytica infection or Amebiasis has an incubation period of 2-3 days to weeks.
Symptoms may include diarrhea and abdominal pains. Stool is almost always heme-positive but
does not usually present as grossly bloody. Prevalence mostly varies depending on the
socioeconomic status but is commonly associated with any uncooked food or food contaminated
by an ill food handler after cooking and also drinking contaminated water.

Other differential diagnoses which commonly manifest diarrhea, abdominal pain and vomiting
among pediatric patients also include:

1. Inflammatory Bowel Diseases such as Chron’s disease usually presents irregular bowel movement,
abdominal pain and vomiting. However, this is mostly common in older ages and chronicity is
highly important in diagnosing this condition.
 2. Pediatric Appendicitis commonly manifests fever, vomiting, and abdominal pain and is mostly
undiagnosed in this age group because very young patients are unable to communicate the
location and nature of their pain.
3. Peptic Ulcer Disease also has common symptoms that include, vomiting, diarrhea, and abdominal
pain.
Imaging studies or endoscopy are required to confirm the said diseases but are only indicated
when the impression of acute gastroenteritis is highly uncertain.

Sources:
WHO Treatment of Diarrhea, 2005
Nelson’s Textbook of Pediatrics, 20th edition

DIAGNOSTICS

1. Thorough history and physical examination include assessment of level of dehydration in order to
provide later the proper requirement of resuscitation and rehydration
2. Complete Blood Count will evaluate volume status which also help confirm whether patient is
dehydrated or not. If infection is suspected, elevated neutrophils suggests bacterial etiology while
elevated lymphocytes may suggest viral cause.
3. Urinalysis/Urine culture will help rule out the presence of urinary tract infection which is also a
possible cause abdominal pain. High urine pH highly suggests bacterial infection. Assessment of
urine specific gravity also help confirm dehydration when value exceeds the normal 1.002 – 1.030.
4. Stool examination with culture is important to know the specific etiologic agent which will aid in
the proper antibiotic treatment. Presence of mucus, blood and leukocytes should also be
examined.

MANAGEMENT

1.
Patient Education: