GENERAL INFORMATION

Name:Gayola zera
Chiel Age :1 yr 6
months
DOB:Dec 28,2023
Sex:Female
Address:Panagan ,davao
city Religion:church of
Christ Informant :Mother
Reliability:98%
Date of interview:July 23 ,2025

CHIEF COMPLAINT:Loose bowel movement

HISTORY OF PRESENT ILLNESS:

2 days prior to consultation ,the LBM began on the afternoon with a frequency of
approximately 5 times per day. The stools were described as watery and brown in color,
with no blood or mucus observed.The child did not receive any medication for the LBM
prior to this consultation. No associated symptoms such as fever, abdominal
distension, were noted during the initial 2 days.

on the day of consultation early morning the child began to have episodes of vomiting
every 2 hours, prompting the visit. The vomitus was milky white in colour ,consistent with
undigested breast milk and non bloody.

PAST MEDICAL HISTORY

No previous hospitalisation,surgeries or maintenance of medication.
No food or drug allergy.

PRENATAL HISTORY
*Regular prenatal checkup( 3 times a month)
*Maternal illness/medications during pregnancy: None
*No complication during pregnancy
*folic acid was taken during pregnancy.
*Substance use during pregnancy: None

BIRTH HISTORY
Type of delivery: Normal vaginal
• Term: Full-term (39 weeks)
• Birth weight and length: 1.8kg
• Delivery complications: None
• APGAR Score: Not

remembered NEONATAL HISTORY

•NICU Admission: No
•Feeding/breathing difficulties: None
• Jaundice or infections: None
*Breastfed from birth

NUTRITION AND FEEDING HISTORY

•Feeding type: Breastfed 10x/day,
•Solid food introduction: 6 months
•Current diet:
Rice,cerlac Food
allergies;none
•Feeding problem : yes vomiting and diarrhea
 IMMUNIZATION

Immunization status: Up to date,Complete and age appropriate

• Missed/delayed vaccines: None
• Adverse vaccine

reactions: None GROWTH

AND DEVELOPMENT

Weight:9.10 kg
• Length: 75 cm
• Milestones appropriate for age
1. Gross Motor
• Walks independently,
• May walk up steps with help
• Can squat to pick up objects and stand again
2. Fine Motor
• Reaches for objects
• Turns pages in a book (2–3 at a time)
3. Language
• Points to show what they want
• Understands and follows simple commands .
4. Social/Adaptive
• Shows interest in other children
• Imitates simple adult actions
• May show signs of temper or fear of strangers

FAMILY HISTORY
•Hereditary diseases: None
• Similar conditions in family: None

PERSONAL AND SOCIAL HISTORY

sleep habits:three times a day

ENVIRONMENTAL HISTORY
*Lives in city
* No pets or smoke exposure
*Recent travel history; samal island

REVIEW OF SYMPTOMS
•General: No fever, (+)fatigue,
•Skin: No rashes, itching
•Head: No trauma, headaches
•Eyes: No redness/discharge
•Ears: No hearing loss or discharge
•Nose: No runny/stuffy nose
•Mouth/Throat: No sore throat or ulcers
•Neck: No stiffness or swelling
•Respiratory: no retraction
•Cardiovascular: No chest pain or cyanosis
•Gastrointestinal: (+)vomiting
•Genitourinary: Normal
•Neurologic: responsive

PHYSICAL EXAMINATION
GENERAL SURVEY
• Appearance: Alert
 • Nourishment/Development: Well-nourished, appropriately developed

VITAL SIGNS AND ANTHROPOMETRICS

•Temperature: 36.2°C
• Weight: 9.10 kg
• Height: 75 cm
• Respiratory Rate: Increased
• O2 Saturation: Not recorded

•SKIN
No rashes, skin pinch go back slowly
•HEAD
Normocephalic
•EYES
Pupils are Equal, Round, and Reactive to
Light. No discharge

•SKIN
No rashes, good
turgor No active
eczema
•HEAD
Normocephalic
Anterior fontanelle open, flat
•EYES
Pupils are Equal, Round, and Reactive to
Light. No discharge

•EARS
No discharge,Responsive to sound

•NOSE
No nasal discharge,No nasal flaring

Mouth: Dry lips

Neck; no stiffness and lymphadenopathy

CHEST AND LUNGS

Equal chest expansion, No wheezing, and
crackles. HEART; Regular rate and rhythm,no
murmur ABDOMEN: soft,globular ,hyperactive
bowel sounds
EXTREMITIES:moves all extremities spontaneously,normal tones,no
deformities,clubbing or cyanosis

•NEUROLOGICAL EXAMINATION
Mental status: Alert,oriented and responsive .

•CRANIAL NERVES
•CN II : Tracks light and objects
•CN III, IV, VI :Eye movements intact, pupils reactive
•CN VII : , no facial asymmetry
• CN VIII : Turns head toward sound CN IX ,X -normal swallowing,cry strong
•CN XI :Moves head side-to-side
•CN XII : tongue movements normal, present in midline

•SENSORY
Intact to touch and pain
•MOTOR
Normal tone and no involuntary movement

SALIENT FEATURES

Pertinent Positives (Findings that support the diagnosis):

• Onset of watery, brown stools (5x/day) starting July 21
• Vomiting started on the day of consultation every 2 hours (milk-
like, non-bilious)
• No fever, no blood or mucus in stool
• Child is breastfed and takes Cerelac
• Recent travel to Samal Island, a possible risk factor for food/
waterborne infection
• Mild dehydration noted on physical exam

Pertinent Negatives (Findings that help rule out other conditions):

• No fever, lethargy, or systemic toxicity
• No blood or mucus in stool (rules against dysentery)
• No history of new food introduction or previous food allergies
• No prolonged diarrhea at this point (rules against chronic
parasitic causes)

IMPRESSION

Acute Gastroenteritis with Mild Dehydration

DIFFERENTIAL DIAGNOSIS

Diagnosis 123. Rule In 124. Rule Out

1. Viral Gastroenteritis - Watery diarrhea- - No fever (but often absent
Vomiting- Age group in mild viral cases)- No
common- Travel confirmatory tests yet
exposure- Mild
dehydration
2. Bacterial Gastroenteritis - Recent travel (possible - No fever, blood, or
food/ water mucus in stool- No signs
contamination)- Acute GI of systemic illness
symptoms
3. Giardiasis (Parasitic) - Exposure to potentially - No prolonged
contaminated water- symptoms- Vomiting not
Watery stools typically persistent in
giardiasis- No foul smell

DISCUSSION

Etiology:
Causes of acute gastroenteritis include:

• Viruses: Rotavirus, Norovirus, Adenovirus (most common in children)

• Bacteria: E. coli, Shigella, Salmonella
• Parasites: Giardia lamblia (particularly in contaminated water

sources) Epidemiology:

• One of the most common illnesses in children under 5

 • Leading cause of childhood morbidity and mortality in low-
resource settings
• Often occurs after travel, during outbreaks, or due to contaminated
food/water

Pathogenesis:

• Viruses or pathogens infect the intestinal mucosa → inflammation →

impaired absorption
• Results in fluid and electrolyte loss, leading to diarrhea and dehydration
• Vomiting due to gut irritation or viral-mediated enteric nervous
system activation

Clinical Manifestations:

• Watery diarrhea (most common)

• Vomiting
• Dehydration signs (dry mucosa, sunken eyes)
• +/- fever, abdominal cramps (depending on the organism)

Diagnosis and Laboratory Findings:

• Clinical diagnosis is often sufficient

• Stool exam (for ova/parasites or fecal leukocytes if prolonged or
bloody)
• Stool culture/PCR: If bacterial or viral cause is suspected
• Electrolytes: If moderate/severe dehydration is suspected

Treatment:

• Oral Rehydration Therapy (ORS)

• Continue breastfeeding and age-appropriate feeding
• Zinc supplementation (10–20 mg/day for 10–14 days)
• Antibiotics only if bacterial etiology confirmed/suspected (e.g.,
dysentery, cholera)
• Antiparasitics (e.g., metronidazole) if Giardia is confirmed

Complications and Prognosis:

131. Possible Complications:

• Dehydration (mild to severe)

• Electrolyte imbalance
• Failure to thrive if prolonged
• Rarely, sepsis (in bacterial
case. Prognosis:

• Excellent in mild cases with proper rehydration

• Most children recover within 3–7 days
• Prognosis worsens with delayed care or severe dehydration
Prevention:
• Hand hygiene
• Safe drinking water and proper food handling
• Rotavirus vaccination
• Breastfeeding (provides immune protection)
• Education on early rehydration at home