I.

INTRODUCTION

Acute Gastroenteritis is an inflammation of stomach and intestinal tract that primarily affects the small bowel. It is usually caused by a viruses, bacteria, parasite and toxins. It can be transferred by direct contact with contaminated food and water. The most common symptoms are mild to moderate diarrhea, dehydration, abdominal cramp, nausea and vomiting and accompanied by fever and generalize weakness. Risk factors include consumption of improperly prepared foods or contaminated water and areas with poor sanitation. It is common among children and elders, for river swimmers to become infected during rainy season as a result of contaminated runoff water. According to the Department of Health there are 6,800 cases of acute gastroenteritis as of 2012. The treatment for this would be oral rehydration which is the prepared method of replacing fluid loss. Antimotility for the treatment of diarrhea and antiemetic drugs may be helpful for vomiting in children.

II.

IDENTIFYING DATA

Name Age Gender Status Address Religion Occupational Date of Admission Time of Admission Name of Hospital Diagnosis

: Mr. XXX : 49 years old : Male : Single : Block 20 Water Dam Gordon Heights Olongapo City : Iglesia Ni Cristo : Construction Worker : March 04, 2013 : 6:15pm : James L. Gordon Memorial hospital : Acute Gastroenteritis with some dehydration

Educational Attainment: High School Graduate

III.

PATIENTS PROFILE

Chief Complaint Loose bowel movement and abdominal pain at epigastric area History of Present Illness 1 day prior to admission, patient stated after eating tinolang manok in Sonias Carenderia at block 1 he suddenly experienced passage of watery stool x 5 episodes associated with abdominal pain at epigastric area, and vomiting. No medication taken. Prompted consult and admitted to James L. Gordon Memorial Hospital. Past Medical History Mr. XXX has never been hospitalized having fever; cough and colds last 2012 and treated it over the counter drugs such as paracetamol, amoxicillin, bioflu.

Family Health History (+) Hypertension Mother Personal and Social History Mr. XXX is a construction worker and has no permanent work. He drinks 4 bottles of red horse amounting 2000 ml per day. Nutritional History Mr. XXX loves to drink coffee in the morning before going to construction site. At lunch he eats 2 cups of rice for his meal, with vegetables or meat. He always drops by at Sonias Carenderia to eat at the end of the day before he goes home. He drinks 4 5 glasses of tap water over the course of each day. (+) Hypertension Father

IV.

REVIEW OF SYSTEM

SYSTEM General Integumentary

MANIFESTATION

Fever Rashes Lesion & scar on right leg Constipation Cough Runny nose

YEAR 3x/year 2009 2010 2010 2x/year 3x/year

CAUSE Due to common illness caused by viruses Due to skin allergy Due to bicycle accident Due to low fiber diet Due to virus Due to virus

Gastrointestinal Respiratory

V.

PHYSICAL ASSESTMENT

Patients Name : Mr. XXX Date Time : March 06, 2013 : 5:00 pm

A. General Appearance Received patient laying on bed, wearing white shirt and walking short, conscious and coherent, with good personal hygiene, no body odor, ambulatory with assistance, cooperative, able to respond to questions, weak and pale in appearance, facial grimace and guarding behavior noted. With ongoing IVF of 0.9 NaCl 1L at 800 cc level, inserted at left metacarpal vein infusing well at 41 gtts/min.

Height: 5 6 Weight: 135 lbs. BMI: 21.79 NORMAL

Underweight : < 18.5 Normal : 18.5 24 Over weight : 25 30 Obese : 30 35

B. Vital Signs Temperature : 38.3 C Pulse RR BP : 94 bpm : 22 cpm : 110/80 mmHg

Body Parts
Skin

Techniques
Inspection

Normal Findings
Uniform whitish pink or brown color. No skin lesions expect for freckles, birthmarks or moles (flat or elevated) Warm to touch, non-tender, feel smooth and dry. Skin turgor or elasticity. No presence of edema. Symmetrically shape can be round. No deformation. No presence of masses or tenderness. Nomocephalic in shape. Black and evenly distributed no presence of lice. Thin, straight, coarse, thick or curly. Shiny and resilient when traction is applied.

Abnormal Finding (actual finding)

Brown in color Presence of scar (right leg) Elevated temperature Dry skin Symmetrically shape can be round. No deformation. No presence of masses or tenderness. Nomocephalic in shape. Black and evenly distributed no presence of lice Thin, straight, coarse, thick or curly. Shiny and resilient when traction is applied.

Interpretati on
NORMAL ABNORMAL ABNORMAL ABNORMAL NORMAL NORMAL NORMAL NORMAL

Palpation

Head

Inspection Palpation

Hair

Inspection Palpation

Scalp

Inspection

White, clean from lumps, White, clean from lumps, masses, lice, nits, dandruff and masses, lice, nits, dandruff and lesions. lesions. No areas of tenderness, without masses. Symmetrically shape can be oval, round or slightly square. No disproportion structure or involuntary movements. No edema, masses or lesions. No areas of tenderness, without masses. Symmetrically shape can be oval, round or slightly square. No disproportion structure or involuntary movements. No edema, masses or lesions.

NORMAL

Palpation Face Inspection

NORMAL NORMAL

Palpation Eyebrows Inspection

NORMAL NORMAL

Black, symmetrically thick raise Black, symmetrically thick raise evenly distributed and parallel evenly distributed and parallel with one another. with one another. Parallel and evenly placed symmetrical, non-protruding with scant amount of secretions. Both eyes are bright and clear. Parallel and evenly placed symmetrical, non-protruding with scant amount of secretions. Both eyes are bright and clear.

Eyes

Inspection

NORMAL

Eyelashes

Inspection

Black evenly distributed and Black evenly distributed and turned upward. turned upward.

NORMAL

Eyelids

Inspection

Upper lid cover a small portion of the iris, sclera and cornea when opened. When the eyes are close the lid meets completely symmetrically. Non-tenderness and nonswelling. White and clear no presence of blood. Transparent, shiny and smooth.

Upper lid cover a small portion of the iris, sclera and cornea when opened. When the eyes are close the lid meets completely symmetrically. Non-tenderness and nonswelling. White and clear no presence of blood. Transparent, shiny and smooth.

NORMAL

Palpation Sclera Cornea Pupils Iris Testing for the eye movement Testing for visual fields Testing for visual acuity Ears Inspection Inspection Inspection Inspection

NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL

Pupils and equally rounded Pupils and equally rounded reactive to light accommodation. reactive to light accommodation. Proportion to the size of the eyes, round, black or brown symmetrical. Able to move the eyes in full range of motion or able to move in all directions. Able to see the stimulus at about 90 temporally. 20/20 vision Proportion to the size of the eyes, round, black or brown symmetrical. Able to move the eyes in full range of motion or able to move in all directions Able to see the stimulus at about 90 temporally. 20/20 vision Symmetrically, parallel, proportional to the head; beanshaped helix is in the line with outer cantus of the eye, skin is same color as the surrounding area clean. Firm cartilage Pink, clean with cant amount of cerumen and a few cilia. No redness, swelling, tenderness, lesion, drainage, foreign bodies or scarily surface areas. Symmetrical in the midline. No swelling, bleeding, lesions or masses. Patent nostril. Pale and dry lips No flaccid and lesions. Foul smelling breath.

Inspection

Ear Canal

Palpation Inspection

Nose Lips

Inspection Inspection Palpation Inspection

Symmetrically, parallel, proportional to the head; beanshaped helix is in the line with outer cantus of the eye, skin is same color as the surrounding area clean. Firm cartilage Pink, clean with cant amount of cerumen and a few cilia. No redness, swelling, tenderness, lesion, drainage, foreign bodies or scarily surface areas. Symmetrical in the midline. No swelling, bleeding, lesions or masses. Patent nostril. Pink and moist with no evidence of lesion or inflammations. No flaccid and lesions. Breath smells fresh.

NORMAL NORMAL

NORMAL ABNORMAL NORMAL ABNORMAL

Mouth

Tongue

Inspection

Bucal mucosa Gums Teeth

Inspection Inspection Inspection

In the midline of the mouth, pink, moist, and rough (from the taste buds) and without lesions. Smooth along the lateral margins. Symmetrical and moves freely. Pinkish, smooth and no inflammation and lesions. Pale red stippled surface. Well defined with no swelling or bleeding. 32 teeth, white with smooth edges and proper alignment without caries, cavity and tooth decay. Concave and pink. The hard palate has many ridges; the soft palate is smooth. No lesions or malformation. Pink and vascular. No swelling, exudates and lesions. Neck is slightly hyper extended, without masses or asymmetry, neck moves freely, color of the neck is same with the body. Muscles are symmetrical with no masses or spasms. Moves up when swallowing. No presence of enlargement, masses or tenderness. Non-visible and non-inflamed. Non-palpable or swelling. Symmetrical, non-involuntary movements. Joint is contour flat in extension and smooth and rounded in flexion. Complete range of motion. Muscle tone is smooth, firm, provides light resistance to passive stretch. External joint is contour, feel smooth, strong and firm. No swelling or edema, pain tenderness or nodules. No deformity. Symmetrical, pinkish palm with visible lines. No lesions, wound infection and bruises.

In the midline of the mouth, pink, moist, and rough (from the taste buds) and without lesions. Smooth along the lateral margins. Symmetrical and moves freely. Pinkish, smooth and no inflammation and lesions. Pale red stippled surface. Well defined with no swelling or bleeding. 29 teeth with presence of dental caries, cavity and tooth decay Concave and pink. The hard palate has many ridges; the soft palate is smooth. No lesions or malformation. Pink and vascular. No swelling, exudates and lesions. Neck is slightly hyper extended, without masses or asymmetry, neck moves freely, color of the neck is same with the body. Muscles are symmetrical with no masses or spasms. Moves up when swallowing. No presence of enlargement, masses or tenderness. Non-visible and non-inflamed. Non-palpable or swelling. Symmetrical, non-involuntary movements. Joint is contour flat in extension and smooth and rounded in flexion. Complete range of motion. Muscle tone is smooth, firm, provides light resistance to passive stretch. External joint is contour, feel smooth, strong and firm. No swelling or edema, pain tenderness or nodules. No deformity. Symmetrical, pinkish palm with visible lines. No lesions, wound infection and bruises.

NORMAL

NORMAL NORMAL ABNORMAL

Palate

Inspection

NORMAL

Throat Neck

Inspection Inspection

NORMAL NORMAL

Palpation Thyroid gland Lymph nodes Upper extremities Inspection Palpation Inspection Palpation Inspection

NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL

Palpation

NORMAL

Hands

Inspection

NORMAL

Palpation Finger nails Inspection

Palpation Breast Inspection

Palpation Thorax and lungs anterior and posterior Inspection

No edema or masses. Warm to touch. Nails should be smooth, surrounding cuticles and tissues clear and normal in color. (pinkish) Normal capillary refill should be two seconds or less. Breast and axillae is fresh colored. Areola and nipples are darker in pigmentation. No edema, symmetrical without deviation. Convex without flattening, free of masses, tumors and lesions. No discharge. No pain is elicited when palpated. Nodular, firm and nontender. Elliptical in shape. Chest contour is symmetrical. Spine vertically aligned. Quiet rhythmic and effortless respiration. Chest wall is intact with no masses, depression, nodules and fractures. Full and symmetric chest expansion. Bilateral symmetry of vocal fremitus. Clear and uninterrupted, moistly, vesicular and louder upon inspiration. Flat or rounded, symmetrical in bilaterally no ridges parallel to umbilicus, uniform in color and pigmentation, no scars, no masses or nodules, umbilicus is depressed and beneath abdominal surface. Intermittent gurgling sounds (5 20x/min). Audible bowel sounds in all quadrants within normal limits. Tympani over the stomach & gas filled bowels; dullness especially over the liver & spleen or a full bladder.

No edema or masses. Warm to touch. Nails should be smooth, surrounding cuticles and tissues clear and normal in color. (pinkish) Normal capillary refill should be two seconds or less. Breast and axillae is fresh colored. Areola and nipples are darker in pigmentation. No edema, symmetrical without deviation. Convex without flattening, free of masses, tumors and lesions. No discharge. No pain is elicited when palpated. Nodular, firm and nontender. Elliptical in shape. Chest contour is symmetrical. Spine vertically aligned. Quiet rhythmic and effortless respiration. Chest wall is intact with no masses, depression, nodules and fractures. Full and symmetric chest expansion. Bilateral symmetry of vocal fremitus. Clear and uninterrupted, moistly, vesicular and louder upon inspiration. Flat or rounded, symmetrical in bilaterally no ridges parallel to umbilicus, uniform in color and pigmentation, no scars, no masses or nodules, umbilicus is depressed and beneath abdominal surface. Hyperactive 30x/min loud and high-pitched. Tympani over the stomach & gas filled bowels; dullness especially over the liver & spleen or a full bladder.

NORMAL NORMAL

NORMAL NORMAL

NORMAL NORMAL

Palpation

NORMAL

Abdomen

Percussion and auscultation Inspection

NORMAL NORMAL

Auscultation

ABNORMAL

Percussion

NORMAL

Palpation Lower extremities Muscle structures, legs and feet Inspection

Palpation

No tenderness; relaxed abdomen with smooth, consistent tension. Symmetrical, non-involuntary movements. Joint is contour is flat in extension and smooth and rounded in flexion. Complete range of motion. Muscle tone is smooth, firm, provides light resistance to passive stretch. External joint is contour, feel smooth, strong and firm. No swelling or edema, pain tenderness or nodules. No deformity.

Light palpation performed to all four quadrants (+) tenderness at RLQ. Symmetrical, non-involuntary movements. Joint is contour is flat in extension and smooth and rounded in flexion. Complete range of motion. Muscle tone is smooth, firm, provides light resistance to passive stretch. External joint is contour, feel smooth, strong and firm. No swelling or edema, pain tenderness or nodules. No deformity.

ABNORMAL NORMAL

NORMAL

10

VI.

LABORATORY

March 06, 2013 Examination Hemoglobin Hematocrit WBC Neutrophils HEMATOLOGY Reference Value Result M:13.5-17.5 g/dL 16.8 g/dL F: 12.0-16.0 g/dL M: 41-53% M:0.52 F: 36-46% 3.5-10.5 x 100 cells/L 4.09 x 100 cells/L 1500 8000 0.71 Interpretation NORMAL NORMAL NORMAL NORMAL

March 06, 2013 Macroscopic Exam Color Transparency Specific Gravity Reaction Protein Glucose WBC RBC URINE ANALYSIS Normal Values Result Amber/Straw Amber Clear Clear 1.015 1.030 1.035 4.5 7 6 Negative Negative Negative Negative 0 6 hpf 0 2 hpf 0 5 hpf 0 hpf Interpretation NORMAL NORMAL INCREASED NORMAL NORMAL NORMAL NORMAL NORMAL

March 06, 2013 Test Color Consistency Fat globules FECAL EXAMINATION Normal findings Result Brown Yellow Soft, formed Watery Moderate Many Interpretation ABNORMAL ABNORMAL ABNORMAL

March 06, 2013 Test Sodium Potassium CLINICAL CHEMISTRY Reference Value Result 135 145 131.9 mmol/L 3.5 5.5 4.31 mmol/L Interpretation Decreased NORMAL

11

VII.

PATHOPHYSIOLOGY

Acute Gastroenteritis defined as diarrhea disease of rapid onset, often with nausea and vomiting, fever, abdominal pain, and loose bowel movement. It is an inflammation of the mucus membrane of the stomach often cause by an infection.
Non Modifiable

Age Sex

Modifiable

Hygiene Environment Contaminated food and water

Ingestion of focally contaminated food and water

Organism affects the body through direct invasion

Release toxin
S/sx: Attempt defecation (tenesmus) S/sx: Hyperactive bowel sound 30x/ minute S/sx: Episode of yellow, watery stool

Stimulation and destruction of bowel mucosal lining

Excessive gas formation

Digestive & absorptive malfunction

Increase in peristalsis movement

GI distention

Diarrhea
Increase fluid loss

Nausea & vomiting

S/sx:

DEHYDRATION

Dry skin Dry lips Pale and weak in appearance

12