Bedside Output

JEHANNA MAR E. ABDURAHMAN

ADZU SOM LEVEL I
 Date of Admission: March 23, 2018
Date of Interview: March 24, 2018
Place of Interview: Ward 8 ZCMC
Source of Information: Mother and Patient
himself
Reliability: 90%

NAME OF PATIENT: E.Q.

AGE: 12 years old
SEX: Male
ADDRESS: Tetuan, Zamboanga City
RELIGION: Roman Catholic
NATIONALITY: Filipino
ETHNICITY: Chavacano
EDUCATIONAL ATTAINMENT: Grade 4

CHIEF COMPLAINT: Loose Bowel Movement

HISTORY OF PRESENT ILLNESS:

Prior to admission (PTA), patient experienced loose bowel movement characterized by 3 episodes
of greenish watery stool estimated to be half cup in amount each. The patient’s mother also reported that
the patient was feverish. Patient’s last intake was milk. Water source of the patient at home is from tap.
No other family members sick. Current medications taken by the patient include folic acid, micro
vitamins and diphenpherox(?)
The patient was diagnosed of Thalassemia at estimated 1-2 mos. old back in 2005. He has been in
and out of the hospital ever since. The patient then underwent splenectomy last May 2017. Patient has no
known allergies noted

PAST MEDICAL HISTORY:

Patient has history of measles and mumps. The patient is fully immunized and has asthma. He
also underwent splenectomy last May 2017.

FAMILY HISTORY:

Patient has relatives with Hypertension, Stroke, Diabetes Mellitus, Asthma and Cancer. The
patient’s maternal grandmother died of colon cancer.

PERSONAL AND SOCIAL HISTORY:

Patient is an only child. The patient stopped going to school for the reason that he often passes
out secondary to his disease condition. He lives with his mother and father on the first storey of their
house while his other relatives lives on the second floor. The patient likes to play with his tablet during
his free time. He also likes to hangout with other children in his neighborhood.
FEEDING HISTORY:

Patient has been bottlefed until 6 mos, introduced to semi-solid foods thereafter. According to the
patient’s mother, the patients usually consumes up to 6 bottles of milk daily and doesn’t usually eat
normal foods charot. The patient also likes to eat cookies and chocolate milk.

REVIEW OF SYSTEMS:

Patient weak, bedridden and responsive. Patient’s weight is 24 kg

GENERAL with recognized weight change and fatigue.

(-) Rashes (+) Lumps (-) Sores (-) Itching

SKIN
(+) Dryness (-) Color change
Head: (-) Headache (-) Injury
(-) Dizziness (-) Lightheadedness
Eyes: (-) Blurred vision (-) Pain (-) Excessive tearing
HEAD, EYES, EARS,
Ears: (-) Discharges (-) Earache (-) Tinnitus
NOSE AND THROAT
Nose and Sinuses: (-) Epistaxis (-) Pain (-) Discharges
(HEENT)
(-) Itching (-) Frequent colds
Throat: (-) Sore throat (-) Hoarseness (-) Bleeding gums
(-) Dentures (-) Sore tongue (+) Dry mouth
NECK (-) Stiffness (-) Nape pain (-) Swollen glands (-) Goiter (-) Lump
(-) Dyspnea (-) Wheezing (-) Cough
RESPIRATORY
(-) Sputum (-) Hemoptysis
CARDIOVASCULAR (-) Palpitations (-) Increased BP
(-) Trouble swallowing (-) Loss of appetite
(+) Frequent bowel movement (Diarrhea with greenish watery stool)
GASTROINTESTINAL
(-) Pain with defecation
(-) Rectal bleeding (-) Abdominal pain
PERIPHERAL (-) Claudication (-) Leg cramps (-) Swelling (-) Tenderness
VASCULAR (-) Varicose veins
(-) Frequent urination (-) Burning or pain during urination
URINARY
(-) Hematuria (-) Flank pain
(-) Muscle or joint pain (-) Stiffness (-) Arthritis
MUSCULOSKELETAL (-) Backache; location (-) Pain (-) Tenderness (-) Swelling
(-) Limitation of motion or action
(-) Nervousness (-) Tension (-) Mood (-) Depression
PSYCHIATRIC (-) Memory change (-) Loss of sensation
(-) Fainting or blackout
(-) Slurred speech (-) Confusion (-) Paralysis
NEUROLOGIC
(-) Seizure (+) Weakness
(-) Excessive sweating (-) Excessive thirst or hunger
ENDOCRINE
(-) Heat or cold intolerance
HEMATOLOGIC (+) blood transfusions (-) easy bruise (+) anemia
PHYSICAL EXAMINATION

❖ GENERAL SURVEY: Patient is bedridden, awake, conscious and responsive with a GCS of 15,
patient is oriented to time and place and obeys command.

❖ VITAL SIGNS: Temperature: 38.2C Pulse rate: 95bpm

Respiratory rate: 28bpm O2 Saturation: 99%

ANTHROPOMETRIC Head circumference: 50 cm Abdominal circumference 74 cm

MEASUREMENTS Height 132 cm Weight: 24 kg
BMI:

❖ SKIN: Some scarring and observed during examination in the lower extremities. Nails are
without clubbing and capillary refill time is less than 2 seconds and with poor skin turgor.
❖ HEENT: The head is symmetrical with equal hair distribution no lumps and tenderness upon
palpation. Eyes are equal, round and reactive to light accommodation, sclera is icteric and the
palpebral conjunctiva appears pale. No periorbital swelling in both eyes nor excessive tearing and
discharges. No ear deformities and discharges noted. Nasal mucosa is pink, septum is in midline
and no sinus tenderness. Lips are dry and oral mucosa is pink with positive gag reflex and patient
is without dentures and with dental caries.
❖ NECK: A lump noted on right side. Distended jugular neck vein is noted.No goiter or swollen
glands noted.
❖ BACK: No lesions or deformities. Shoulder height is symmetrical, no rashes, bruising or
tenderness.
❖ RESPIRATORY: Thorax is symmetrical with good excursion. Resonant on percussion, with
normal vesicular breath sounds upon auscultation. No redness or lumps on the chest. No
wheezing or rales noted.
❖ CARDIOVASCULAR: JVP was not observed. Heart sounds are normal no murmurs or bruits
noted.
❖ ABDOMEN: Abdomen is globular and distended. Scar on left upper quadrant noted.
Normoactive bowels sound on auscultation with a rate of 7 bowel sounds per minute. Tenderness
was noted on right lower quadrant. Hepatomegaly was also noted.
❖ GENITALIA & RECTAL: Not assessed
❖ EXTREMITIES: Warm and with traces of pitting edema on the lower extremities. No stasis
pigmentation or ulcers. Bruises noted on the left lower extremity.
❖ MUSCULOSKELETAL: No joint deformities. Good range of motion in hands and wrist.
❖ NEUROLOGIC: Weak but cooperative. Oriented to time and place, obeys command and has
spontaneous eye opening. GCS of 15
CLINICAL IMPRESSION

ACUTE GASTROENTERITIS

History Physical Examination

● 3 episodes of greenish watery stool ●

estimated to be half cup each PTA

DIFFERENTIAL DIAGNOSIS:

RULE IN RULE OUT

BACTERIAL GASTROENTERITIS

● DIARRHEA ● VOMITING
● ABDOMINAL DISCOMFORT
● FEVER
AMEBIASIS

● ●

CROHN’S DISEASE
● ●
ULCERATIVE COLITIS
● ●

CHOLERA
● ●

PARACLINICALS
 FECALYSIS
 URINALYSIS
 ELECTROLYTE PANEL
 CBC
 LIVER ENZYMES??
 HEMO- COAGULO

MANAGEMENT
1. Replace fluid loss by initiating an IV line to facilitate fluid replacement
2. Consider antibiotic therapy if disease is confirmed as bacterial in nature
3. Administer anti-pyretics for fever
4. Assess for any untoward complications
5. Encourage adequate fluid intake and nutrition