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Diarrhea
History of Present
Illness
2 weeks PTC Change in milk formula
Consultation
ROS
■ Skin ■ Respiratory:
– (-)Rashes – (-) difficulty of breathing
– (-)Color changes – (-) cough
– (-)Pigmentation ■ Urinary
■ HEENT – (-) frequency
– (-)Colds ■ Nervous:
– (-)Ear discharge – (-) vomiting
■ Neck – (-) convulsions
– (-) masses – (-) weakness or paralysis
■ Cardiovascular
■ Hematopoietic:
– (-) pallor
– (-) cyanosis
– (-) bleeding
manifestations
Gestational history
■ 17 y/o
■ G1P1 (1-0-0-1)
■ healthy
■ good nutrition
■ no infections
■ no intake of drugs
■ 9 months gestation
Birth History
■ Full term
■ NVSD
■ Physician attended at birth
■ Birth weight: 6.8 lbs
■ No complications during birth
Neonatal Condition
■ spontaneous respiration (cry)
■ acyanotic
■ no pallor or jaundice
■ no convulsions
■ no hemorrhage or feeding difficulties
Feeding History
■ Breast fed: (form birth to present)
– Interval: every 3-4 hours
– Duration: 40 mins. – 1 hr.
■ Mixed (Bottle fed and
breastfeeding) at 5 months
■ Present feeding: infant cereal mix
(cerelac) and bottle fed
Growth and Development:
■ Lift head on prone: 2 month
■ Smiles socially: 2 months
■ Visual tracking: 2 months
■ Reaches for toys: 4 months
■ Rolls over: 5 months
Growth and Development:
■ Developmental Reflexes
– Moro: Absent
– Palmar and Plantar Grasp: Present
– Rooting and sucking: Absent
– Tonic Neck Reflex: Absent
Immunizations
INFECTIOUS NON-INFECTIOUS
- Bacterial - Anatomic
- Viral - Malabsorption
- Parasitic - Endocrinopathies
- Food Poisoning
- Neoplasms
Differentials
(least to most likely)
■ Neoplasm
- Neuroblastoma, Ganglioneuroma,
Pheochromocytoma, Carcinoid
- not considered because diarrhea was
of acute onset, (-) family history, no
other accompanying symptoms such as
abdominal mass, distention, vomiting,
weight loss and extraintestinal
manifestations
Differentials
■ Anatomic causes
- Malrotation - no episode of bilious
emesis or recurrent abdominal pain
- Intestinal duplication – no palpable
mass or vomiting
- Hirschprung disease – no reported
delayed passage of meconium
Differentials
■ Malabsorption Syndrome
- no family history of malabsorption
disorders; abdominal distention;
failure to thrive; pale, foul-smelling,
bulky stools; weight loss; muscle
wasting.
Differentials
■ Food Poisoning
- patient has only been breast- and
formula-fed since birth
- no reported episode of accidental
ingestion of toxic compounds
Differentials
■ Infection
- no fever, cramping abdominal
pain, or vomiting
- diarrhea was not profuse and
appeared only after the patient
was bottle-fed
Differentials
■ Cow’s Milk Intolerance
- most likely consideration
- usually in infants 6 months and
below who have been introduced
to formula feeding
- protein in cow’s milk is the most
common offending agent
Clinical Impression
Non-infectious diarrhea d/t transient
milk intolerance
Mild PEM
Pathophysiology
Diarrhea
■ An increase in stool volume and
frequency of defecation
■ Defecation of more than
10g/kg/day in infants and children
wherein the stools follow the shape
of the container
■ Stool is usually watery and loose
■ It is the most common clinical sign
of gastrointestinal disease
Diarrhea
■ Diarrhea occurs when insufficient
fluid is absorbed by the colon
■ Absorption of water in the
intestines is dependent on
adequate absorption of solutes. If
excessive amounts of solutes are
retained in the intestinal lumen,
water will not be absorbed and
diarrhea will result.
Osmotic Diarrhea
■ 2 mechanisms:
1. Ingestion of a non-absorbable
solutes – usually a carbohydrate or a
divalent ion, e.g. sorbitol or manitol,
epson salt and some antacids
2. Malabsorption – inability to absorb
certain carbohydrates, the most
common would be lactose
intolerance
Treatment
■ Continue milk formula
Dietary Prescription
■ 6 months old / Female
■ TER = weight @P50 x Calorie
(kcal/kg)
■ = 7.2 kg x 90 kcal/kg
(throughout the first year
of life)
■ TER = 648 kcal/ day
Dietary Prescription
March 1990
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Legends:
- Index Patient
Josea Elisa Riyana - Diarrhea
9 months 6
months - Asthma
- Bad relationship
- good relationship
- very good relationship
Map
San Martin de
Porres Socio-
Medical
Center
Family Profile
Name Age Sex Civil Relation to head Educational Staying
status of family attainment with
family?
Ordinal Position of Index Patient First and only child of Ryan and
Criselda
Parent Child Interaction Active relationship of mother only
to the child
Social Class Pattern Low Income
Total P 12,800/month
FLOOR PLAN
window window
SALA BED
entertainment
door
center
door
LAUNDRY
KITCHEN Washing
Machine
BATHROOM
BED
Ref
TABLE
Divider
Environmental Profile
Dwelling Unit 1 house, bungalow type;
owned by grandmother
Type Concrete and wood
No of Bedrooms 2
Appliances TV, VHS, radio, electric fan,
refrigerator, electric flat iron,
washing machine
Cleanliness/Order Moderately clean
Ventilation Poorly ventilated
Others Ryan