I-human samantha graves case study

Diet Blood in stool Around any sick people Allergies New meds Otc meds Wet diapes Stool diapers How often is she nauseous or vomiting When and what did she last eat When and what did she last drink Key findings: v/d for past 2 days about 4-5 times per day diarrhea 3-4 times per day sister had similar symptoms last week reduced appetite slightly reduced amount of wet diapers per day can tolerate some Pedialyte and milk ddx gastroenteritis, bacterial gastroenteritis, viral lead - A08.4 gastroenteritis, parasitic appendicitis MNM intussusception, ileocolic. MNM dehydration. MNM tests performed: stool examination for ova and parasites (O&P)- 87177 stool culture - 87045 Reason for encounter: The patient is an 18-month-old girl brought in by her mother with a complaint of vomiting and diarrhea for the past 2 days. The patient’s parent is concerned about her reduced appetite. HPI: The patient is an 18-month-old girl brought in by her mother who presents to the clinic with a complaint of vomiting and diarrhea for the past 2 days. Her diarrhea began first and then she started vomiting. The patient usually has 5-6 wet diapers but day but for the last 2 days, she has only had 4 wet diapers per day. She used to have 2 formed stools per day but now she has had watery stools 3-4x per day for the past 2 days. The patient vomits 4-5 times per day and This study source was downloaded by from CourseH on 06-08-2023 04:01:08 GMT -05:00 her vomit looks like milk with small bits of the food she just ate. The patient's sister had similar symptoms last week that resolved within two days. The patient’s parent denies any blood in her stools; diarrhea is watery and runny. The patient is becoming more fussy and irritable. Can tolerate some Pedialyte and milk Diet- before this d/v started she was eating food and drinking her milk as usual. She used to drink about 12-15 oz of whole milk per day and eating table foods. She has a well rounded healthy diet. ROS: No fever, alert, with warm and dry skin. The patient has a reduced appetite and is fussy and irritable. HEENT/ Neck : No recent head trauma or HEENT complaints Cardiovascular: no hx of murmur or SOB. No hx of fainting or excessive sweating Respiratory: denies cough or difficulty breathing Gastrointestinal: vomiting and diarrhea present for the past 2 days; vomiting looks like milk and small bits of food; Denies any blood in stools; diarrhea is watery and runny; the patient used to have 2 formed stools per day, now she has watery stools 3-4x per day for the past 2 days; patient vomits 4-5 times per day Genitourinary: The patient usually has 5-6 wet diapers but day but for the last 2 days she has only had 4 wet diapers per day; No hx of uti’s in the past. Musculoskeletal/ Osteopathic structural examination: no recent trauma, no. weakness, no limping Neurologic : no hx of seizures Integumentary/ breast: Psychiatric: child is irritable and fussy for the past 2 days Endocrine: no hx of diabetes, adrenal or thyroid dysfunction Hematologic/ lymphatic : no hx of anemia