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When I was young and free and

my imagination had no limits, I


dreamed of changing the world.
As I grew older and wiser, I
discovered the world would not
change, so I shortened my sights
somewhat and decided to change
only my country.
But, it too, seemed immovable.
As I grew into my twilight years,
in one last desperate attempt, I
settled for changing only my
family, those closest to me, but
alas, they would have none of it.
And now as I lie on my deathbed,
I suddenly realize:If I had only
changed my self first,then by
example I would have changed
my family.
From their inspiration and
encouragement, I would then
have been able to better my
country and, who knows, I may
have even changed the world.
ADMITTING CONFERENCE
JUNIOR INTERN NAOE, MARCO PAULO R.
GENERAL DATA;
JM

29y/o
Male
Filipino
Married
Roman Catholic
Born on 21-Sept-1987, Itogon, Benguet

Residesin Ampucao Itogon Benguet


Admitted for the 1st time at our institution
CHIEF COMPLAINT:

Abdominal Pain
HISTORY OF PRESENT ILLNESS

5 days PTA
Patient experienced sudden onset
abdominal pain, located in the
epigastric area, crampy, no aggravating
nor alleviating factors, nonradiating,
intermittent rated 5-6/10. With
associated loose bowel movement of 2-3
episodes. There were no nausea, no
vomiting, no loss of appetite, no fever.
No consult was made. No medications
were taken.
HISTORY OF PRESENT ILLNESS

One Day PTA

Patient had persistence of symptoms.


A consult to a Family Physician was
made and was prescribed with the ff:
Omeprazole 40mg BID
Domperidone 10mg BID
HISTORY OF PRESENT ILLNESS

Few Hours PTA


Epigastric pain progressed to 8/10 not
aggravated by food intake
2x non projectile vomiting, previously
ingested food
3x diarrhea, brown watery-mucoid stools
Poor oral intake
With feelings of bloatedness, and
increased burping
No fever and dysuria.
PAST MEDICAL HISTORY
No history of hypertension, diabetes, bronchial
asthma, CAD, CVD

No history of previous hospitalizations

No surgeries and trauma

No known allergies to food and medications


FAMILY HISTORY
(-) hypertension
(-) cardiovascular disease
(-) diabetes mellitus
(-) asthma
(-) cancer
(-) PTB
(-) allergies
SOCIAL AND ENVIRONMENTAL
HISTORY
Previous smoker (1 pack year, 2012-2013)
Occasional alcoholic beverage drinker

Denies elicit drug use

Patient eats mostly everything but prefers


vegetables, meat, and fatty food.
The Patient works as a miner for ~5 years

Drinking water is from Water Refilling Station

Water for daily use is from Water District


No history of travel
No family member with the same symptoms
REVIEW OF SYSTEMS
*General. (-) weight loss, (-) weakness, (-) fever
*Skin. No rashes, lumps, sores, color change
*Head, Eyes, Ears, Nose, Throat.
Head. No headache, dizziness, lightheadedness

Eyes. No redness, no double vision,

Ears. No earaches, tinnitus, discharge.

Nose and sinuses. no itching, no nosebleeds,


nasal stuffiness, discharge, colds
Throat (or mouth and pharynx). No difficulty

swallowing , no dry mouth. No hoarseness.


*Neck. No lumps, no swollen gland, no neck
stiffness
*Respiratory. (-) Difficulty Of Breathing, (-) cough,

*Cardiovascular. No palpitations. No chest pain.


No chest discomfort.
*Gastrointestinal. (+) loss of appetite.(+)
abdominal pain. (+) diarrhea, no constipation. No
Black Stools
*Urinary. No polyuria, nocturia, hematuria,
dysuria, no flank pains, no incontinence
*Genital. No lesions, no discharge, no itching, no
sores.
Musculoskeletal. No muscle or joint pains. No
stiffness.

Neurologic. Now blackouts, no seizures, no


paralysis, no tremors nor tingling sensations.

Endocrine. No excessive thirst or hunger. No


temperature intolerance. No excessive sweating.
PHYSICAL EXAMINATION
General: Ambulatory, coherent, noted
grimacing, patient assumes a fetal
position.
Vital signs:
BP: 120/80mmHg HR:93bpm
RR: 19 T: 36.4C Wt: 63kg, Ht: 54
BMI: 23.84kg/m2
Skin: No jaundice, no cyanosis, no pallor
no rashes, no scars, warm to touch good
skin turgor
HEENT: pink palpebral conjunctivae,
anicteric sclerae, no nasoaural discharge,
no tonsillopharyngeal congestion,
(-) distended neck veins, no anterior neck
mass, (-) cervical lymphadenopathies (+)
dry lips, (+)dry buccal mucosa

Chest and Lungs: Symmetrical chest


expansion, resonant on all lung fields,
clear breath sounds.
Heart: apex beat at 5th ICS along the LMCL,
no heaves, regular rate and rhythm

Abdomen: flat, no scars, hyperactive bowel


sounds, (-)bruit, hypertympanitic, (+) direct
tenderness on epigastric and right lower
quadrant. No rebound tenderness. No
Rovsings sign, No Dunphys sign, No Heel
Jarring sign. No Psoas sign. No Obturator
sign (-) Murphys
Extremities: No gross deformities, Good
Peripheral Pulses. CRT < 2sec.

Digital Rectal Exam: Refused by the patient.


SALIENT FEATURES
Subjective
29 y/o Male
Abdominal Pain,
non projectile vomiting, previously ingested
food
diarrhea, brown watery-mucoid stools
Poor oral intake
With feelings of bloatedness, and increased
burping
No history of travel
No family member with the same symptoms
OBJECTIVE FEATURES
Objective
Ambulatory, coherent, noted grimacing
BP: 120/80mmHg HR:93bpm RR: 19
T: 36.4C, Wt: 63kg, Ht: 54 BMI: 23.84kg/m 2
(+) dry lips, (+)dry buccal mucosa
Flat abdomen, no scars, hyperactive bowel
sounds, (-)bruit, tympanitic, (+) direct
tenderness on epigastric and right lower
quadrant. No rebound tenderness. No
Rovsings sign, No Cough sign, No Heel
Jarring sign. No Psoas sign. No Obturator sign
(-) Murphys
IMPRESSION

Acute Gastroenteritis
with Moderate Signs of
Dehydration
ACUTE GASTROENTERITIS
Generally associated with other signs or
symptoms including nausea, vomiting, abdominal
pain and cramps, increase in intestinal gas-
related complaints, fever, passage of bloody stools
(dysentery), tenesmus (constant sensation of urge
to move bowels), and fecal urgency. (1)
(1) Guidelines on acute infectious diarrhea in adults. The Practice Parameters Committee of the American College of
Gastroenterology. American Journal of Gastroenterology. 1997 Nov;92(11):1962-75.
IMPRESSION
IMPRESSION
DIFFERENTIAL DIAGNOSIS

Bacterial Viral
Cause Nature of Location and Associated Precipitating
patient nature of pain Symptoms and aggravating
factors

Acute Alcoholic patients Epigastrium; Nausea, vomiting, Alcohol, NSAIDS,


Gastroenteritis Constant burning diarrhea, fever, food, salicylates
hemorrhage

Acute Alcoholic patients, Epigastric, Nausea, vomiting Alcohol, lying


Pancreatitis as well as those radiates to the supine
with cholelithiasis back

Peptic Ulcer 30-50 yrs. Old; Epigastric Empty stomach,


M>F radiating to the Stress, Alcohol
back or right
shoulder

GERD Midepigastrium Chest pain, reflux,


radiating to the regurgitation
jaw, Burning,
gnawing

Myocardial Hypertensive; 40- Chest pain; may


Infarction 70 yrs. old also present with
abdominal pain
ACUTE APPENDICITIS
ACUTE APPENDICITIS
Viral gastroenteritis presents
with nausea, vomiting, low-grade
fever, and diarrhea and can be
difficult to distinguish from
appendicitis.
PLAN
Admit the patient
ACUTE GASTROENTERITIS
When to admit?
Persistent Diarrhea (>7 days) (2)
Fever
Unstable
Severely dehydrated
Bloody diarrhea
Persistent Vomiting
No improvement after initial hydration or
symptoms exacerbate/ overall condition gets
worse (6)
(2) Acute Infectious Diarrhea. Nathan M. Thielman, M.D., M.P.H., and Richard L. Guerrant, M.D. The New England
Journal of Medicine. 2004; 350:38-47

(6) World Gastroenterology Organisation (WGO). WGO practice guideline: acute diarrhea. Munich, Germany: World
Gastroenterology Organisation (WGO); 2008 Mar.
DX:
CBC

UA

Stool Exam

TX:
PNSS 1L x 49gtt/min
Monitor Abdominal Status
PATIENT EDUCATION
Many diarrheal diseases can be prevented by
following simple rules of personal hygiene and
safe food preparation.
Hand-washing with soap is an effective step in
preventing spread of illness and should be
emphasized for caregivers of persons with
diarrheal illnesses.
As noted above, human feces must always be
considered potentially hazardous, whether or
not diarrhea or potential pathogens have been
identified. (3)
(3) Practice Guidelines for the Management of Infectious Diarrhea. Infectious diseases Society of America. Clinical Infectious Diseases 2001; 32:33150.
ACUTE GASTROENTERITIS
When to discharge?
Stable Vital signs
Maintains a sufficient fluid intake
Able to eat meals adequately
Able to take medications (if still indicated) (6)

(6) World Gastroenterology Organisation (WGO). WGO practice guideline: acute diarrhea. Munich, Germany: World
Gastroenterology Organisation (WGO); 2008 Mar.