Health and Physical Assessment

CC: 

“ Ruth had a gastroenteritis and was discharged from the hospital” 

HPI: 

Ruth is a pleasant 6 year old girl who has been presented to the clinic today with a complaint of contracting an acute gastroenteritis resulting to hospitalization. It is reported that the infant had previously passed 8 watery tools for the past 48 hours, resulting in restlessness, frequent cries, and subsequently reducing her usual liquids intake by half (Guzganu, 2012). Ruth’s medical history indicated that severe fetal distress had resulted into her delivery term via emergency cesarean section (Lurie & Mamet, 2003). She had recorded a birth weight of 2890 g. She was put under tracheal intubation and later transferred to neonatal intensive care unit (Lurie & Mamet, 2003). No history of induced coma or hypothermia indicated. MRI test done on the 5 th day of her life presented signs of mild hypoxic-ischemic encephalopathy (Guzganu, 2012). No vaccine had been administered to Ruth at the time of hospitalization. 

She weighed 4480 g at current admission, raising a big concern over her weight curve (Guzganu, 2012). Physical examination at the date of current admission revealed that she was alert. However, she appeared irritable, with a body temperature of 38.7 0 C. Her heart rate ranged between 171 and 189 beats per minute. She had a respiratory rate of between 39 and 79 breaths per minute and a blood pressure of 101/54 mmHg, while her oxygen saturation by pulse oximetry is 100% (Guzganu, 2012). Skin examination indicated that her skin was pale grey, dry lips, dry mucosa, and tenting skin turgor (Guzganu, 2012). She had normal eyes, capillary refill time of 3 seconds, and soft fontanele (Guzganu, 2012). However, the infant had reduced tears and urine. 

She had normal lungs and heart, but abnormal tachycardia; in that she had a swollen abdomen, with some pains on palpation (Kirk Veitch, & Hall, 2010). Her thorax and abdominal radiographs were normal, and no hepatosplenomegaly observed (Kirk Veitch, & Hall, 2010). No meningeal irritation signs observed, while laboratory tests indicated that she had 12.7 g/dl of hemoglobin, 11971/mm 3 of the white blood cells, 1085 000/mm 3 of platelets, and her C-reactive protein recorded below 0.05 mg/dl (Kirk Veitch, & Hall, 2010). Although she recorded positive for her rotavirus antigen, her blood and urine were negative (Kirk Veitch, & Hall, 2010). 

Medication: 

Denies any fold or herbal medicine. 

Intravenous fluid therapy for tachycardia, low pH, and Polypnea. 

0.9% NaCl at 20mL/kg over an hour for volume repletion. 

5% dextrose solution for hypernatremia. 

ORS for digestive loses. 

Gelatin tannate (one sachet for every six hours) for diarrhea and adjuvant treatment. 

Aspirin 5 mg/kg/day for antiplatelet treatment. 

Lactobacillus GG for intestinal microbial balance. 

Saccharomyces boulardii for adjuvant treatment to ORS. 

Ceftriaxone 100 mg/kg/day for antibiotic treatment. 

Fluid and electrolyte replacement for severe dehydration and acidosis. 

Tannins for local inflammation. 

PMH 

Allergies: None 

Medication Intolerance: None 

Chronic Illness/Major traumas: No significant history of chronic illness or major trauma. 

Chronic Health Problems: 

Bipolar disorder. 

Crohn’s disease, diagnosed in 2017. 

Posttraumatic stress disorder. 

Partial hysterectomy in 2016. 

COP (491)- controlled 

Muscular degeneration 

Hospitalizations/Surgeries: No surgery reported. 

Other: 

Immunizations: None 

Environmental hazards: The infant is rarely exposed to environmental hazards. She lives at home with her mother and is under constant check against visiting any dangerous places, such as stagnant waters. She has access to clean and adequate water. However, she is likely to suffer from malnutrition due to poor income of the family. 

Exercise and leisure: She interacts and plays well with the other children, hence receiving substantial exercise. She is able to walk from one house to the other, and she is playful. 

Sleep: The patient receives enough sleep. She sleeps for about 4 hours during the day, and retires to bed early at night (most around 2000) and sleeps well until late in the morning (mostly wakes up at around 0700). She does not take naps. 

Diet: Takes a cup of milk per day and about 1.6 liters of water per day. Breakfast mainly made of bread and porridge. Her lunch keeps changing, with most of the time being made of potato chips. She occasionally takes turkey sandwiches for lunch. Her dinner is primarily made of snacks and pepperoni pizza. She sometimes takes rice and chicken for dinner. Her fluid restriction is 1800 ml. 

Family History 

Ruth’s parents are all alive and healthy. She has two brothers and a sister; all alive and without complicated illnesses. However, her grandmother died at 79 years and had some cases of hypertension. The other grandparents had no serious health complications. No history is known about her great grandparents from either side. 

Social History 

Ruth is an infant and, therefore, limited social history. Her parents are non-smokers and deny abusing any drug. 

General 

Admits abdominal pain, nausea, and vomiting. She has high fever, has signs of fatigue, and serious weight loss. However, she denies night sweats and chills. 

Cardiovascular 

No signs of chest pain, PND, edema or palpitations. 

Skin 

Her skin appears pale grey, has dry mucosa, and lips. However, she denies any rash, bruising, cuts, and itching. 

Respiratory 

Admits to a mild wheezing and unproductive cough. Denies hemoptysis, SOB or tuberculosis. 

Eyes 

Has good vision. Denies eye pain, redness, flashing lights or diplopia. 

Gastrointestinal 

Admits to abdominal pain, nausea, and vomiting, and mild diarrhea. Denies dysphagia, blood in tools, dyspsia, or tarry tools. 

Ears 

Denies hearing loss, discharge, ear pain, or tinnitus. 

Genitourinary/Gynecological 

Denies any discharge. No more information available since she is still and infant. 

Nose/Mouth/Throat 

Admits to throat pain and dryness. 

Denies use of dentures and hoarseness. 

Musculoskeletal 

Denies back pain, stiffness, fracture, joint swelling, or osteoporosis. 

Breast 

Denies SBE, changes, bumps, or lumps. 

Neurological 

Admits to numbness and body emaciation. 

Denies paralysis, head injuries, headaches, parasthesias, tremor, memory loss or focal weakness. 

Heme/Lymph/Endo 

Admits to increased thirst and loss of appetite. 

Denies bleeding, night sweets, swollen glands, heat intolerance, or blood clots. 

Psychiatric 

Denies any depression, anxiety, or sleeping difficulties. 

General Appearance 

Ruth is a pleasant 6 year black Caucasian girl. She appears active and moderately energetic. Although she appears appropriate, her weight curve raises great concern and calls for more attention to restore. 

Skin 

Her skin appears pale grey, has dry eyes, and lips. However, her skin is intact, warm, has no bruises, no lesions, or rashes. Besides, her skin is clean and appears generally healthy. 

HEANT 

Head: Head is tender, normocephalic, and no palpation. 

Eyes: Eyes have white sclerae without jaundice and conjunctiva pink. 

Ears: Tympanic membrane intact, no cerumen on external auditory canal, and no pearly gray noted. Moist nasal mucosa with no damage, septum midline, nor lesions, or exudates. 

Teeth: Teeth intact and growing normally. 

Neck: No JVD, lymph nodes palpate or palpable thyroid. 

Cardiovascular 

S1 and S2 with regular rate and rhythm. No extra sounds noted. Capillary refill 2 seconds. No edema, with pulses 3+ throughout. 

Gastrointestinal 

Distended abdomen, with bowel sounding present across the four quadrants. No hepatosplenomegaly or abdominal tenderness noted. 

Breast 

No difference noted for breast exam at this time. 

Genitourinary/Gynecological 

Lacks tenderness on the bladder, CVA, or any difference on GYN. Skin color observed to be in consistence with the normal pigmentation. Vulva lacks lesions. 

Musculoskeletal 

No joint pain, warm, swelling, crepitus, or tenderness. Full ROM. 

Neurological 

Patient has an upright body posture, clear speech, good balance, and normal gait. 

Psychiatric 

Maintains eye contact and has soft speech. However, she often loses alertness. 

Lab Tests 

None 

Wet prep- pending 

Urinalysis- pending 

Urine culture- pending 

Special Tests 

None 

Differential Diagnosis 

Diarrhea (resolved). 

An acute gastroenteritis. 

Presumptive Diagnosis 

Diarrhea (resolved). 

Plan 

Diagnosis: An acute gastroenteritis. 

Further testing: None done 

Medication: None done 

Education: Records confirmed that the patient was injected with rotavirus vaccinations while in the hospital (Edwards, 2011). The parents of the infant were also educated on the importance of visiting the clinic regularly and have their daughter be given all the important vaccines. The possibility of recurring of gastroenteritis was also discussed, where the parents of the patient were advised to be observant and report back to the hospital as soon as they see the signs of the gastroenteritis, such as vomiting, watery diarrhea, and mild fever (Edwards, 2011). It also came out that a new vaccine that contains VLP antigens was under test and could be available for use in the near future (Edwards, 2011). Therefore, the parents were advised to visit the clinic as soon as the new vaccine becomes available for use to have their daughter vaccinated against the notorious disease. Ruth is born to poor black American parents and thus her health is in danger. The parents lack enough funds to cater for their medical cover. The parents were advised to use the little funds they have to start a business that could help to improve their living standards in future. 

Non-medication treatments: Generally, gastroenteritis does not always need medical treatment to cure; the virus can run its course after a few days of infection (Cunha, 2019). However, the symptoms of gastroenteritis, such as diarrhea and vomiting, may be corrected through keeping the patient hydrated (Cunha, 2019). In this case, the girl was given sports drinks to help her recover without too much of drugs (Cunha, 2019). Besides, a pedialyte solution was used to rehydrate the patient (Cunha, 2019). Since the girl was faring well on the fourth day and could keep food down, saline crackers were offered to facilitate her recovery (Cunha, 2019). Finally, the patient was given BRAT diet to help her transition easily backing to her regular diet (Cunha, 2019). In this way, Ruth’s health was restored and she was ready for discharge. 

On admission, the patient was rigorously examined and was diagnosed with an acute gastroenteritis. She was admitted on 11/20/2019 where she was subjected to intravenous fluid therapy aimed at correcting her tachycardia, blood pH, and polypnea (NHS, 2019). For slow correction of hypernatremia, she was given a 5% dextrose solution, as well as electrolytes (NHS, 2019). Throughout her stay in the hospital, the baby showed an outstanding digestive tolerance. She also responded well to medication and was ready to be discharged by 11/26/2019, six days after admission. The patient was friendly and interacted well with the healthcare providers. Besides, her parents responded well to all the questions asked by the healthcare professionals. 

The mother of the infant was always to take instructions from the doctors. Although the mother initially tried to hide some background information regarding the patient, she was urged by the doctors to reveal all the information for better care of her child (Silfen, 2006). She understood and gave a true record of the patient’s medical history, thus leading to best patient care system (Silfen, 2006). The mother also offered to ensure that the baby receives all the vaccines and keep her under intensive medical examination to better her health (Edwards, 2011). Above all, the parents received the education they were offered by the healthcare providers and offered to act according for a healthy family.