Subjective History
The patient is a 10-year-old male with a five-day history of diarrhea and a four-day history of emesis. The brother also presented with similar symptoms. Although there was some language barrier, the father of the patient was able to relay that the two brothers had chicken which they, later on, ate in the next day. However, sine then they have been feeling bad as they presented with the symptoms described earlier. The patient described that he has had diarrhea four to five times in a single day for the last five days as well as emesis quite frequently for the past four days and has had a couple of it every day for the last three days. No emesis has been experienced today. He says that he micturated this morning. Both parents are deeply concerned since the patient had a fever of 39 degrees delicious last night. In addition, he ate half a sandwich yesterday and also tried drinking some milk after which he had an emesis. Since then, he has been drinking white grape juice, 7Up, and Pedialyte, otherwise, he has not been taking any food.
Objective Data
General assessment: the patient is alert and awake, with no acute distress.
Vital signs: Blood pressure: 108/78. Temperature: 38.9. Pulse rate: 124 regular. Respiratory rate: 24. Weight is 53 pounds.
HEENT: The posterior pharynx is unremarkable and the tympanic membranes are normal bilaterally.
Nek: Thyromegaly and adenopathy are absent.
Lungs: Clear on auscultation.
Heart: murmurs are absent and the rate is regular.
Abdomen: Benign.
Skin: The turgor is intact with a capillary refill of fewer than 3 seconds.
Gastroenteritis. The symptoms of emesis, diarrhea, elevated temperatures, and white blood cell count together with nausea and loss of appetite are all typical of gastroenteritis. Some of the risk factors include poorly cooked food or even cooked food that has been stayed for long within room temperature hence promoting the growth of bacteria as the food acts as a culture. This might be the case for the reason as to why the patient got the gastroenteritis since he did not reheat the chicken he had eaten the previous day. Other risk factors include lack of sanitation and poor personal hygiene as well as a compromised immune system which increases the susceptibility of the patient in contracting gastroenteritis (Graves, 2013).
Plan
The parents did not update me of the rash that the patient had on his buttock. I realized that there some small papules that formed erythematous patches with a scab on them. However, I did not find any evidence of petechiae. Hence, I went forward and reassured them that that is gastroenteritis. Some of my recommendations for them included: that they stop giving the patient juice and instead give him water. I also recommended that the patient is to stay away from dairy products until the stomachaches and diarrhea have calmed down. We also talked of BRAT (Bananas, Rice, Applesauce, and Toast) diet and progressively advancing the diet with an increase in tolerance. I went ahead to explain the significance of BRAT diet in the recovery of the patient from diarrhea and upset stomach since it includes “binding” foods that are low in fiber hence making the stool firmer. In addition, the bananas in the that BRAT diet are high in potassium and also aid in replacing the nutrients that have been lost by the body due to diarrhea and vomiting (Elliott, 2007). I also advised on the need to monitor the frequency of the episodes of diarrhea and emesis so as to keep track of the progress of treatment. They have already tried using some Kaopectate which did not aid with diarrhea. I also advised on measures of preventing further spread of infection such as thorough hand washing, separate washing of soiled bed linen and clothing as well as not sharing flannels and towels. Follow up will be conducted as needed.
References
Elliott, E. J. (2007). Acute gastroenteritis in children. Bmj, 334(7583), 35–40.
Graves, N. S. (2013). Acute gastroenteritis. Primary Care, 40(3), 727–41.
