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8/2/2019 AGE for Case Pres.
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Patient: RJ De Torres
Address: Malitam, Batangas City
Age: 1year old
Gender: Male
Religion: Roman Catholic
Status: Child
Hospital No.: 481214
Admitting Diagnosis: Acute Gastroenteritis with signs of moderate dehydration
Physician: Dr. Maricel Villapondo
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Clinical Appraisal
General Survey:
Patient lying on bed, awake with D5LR @ 19-20 drops/min inserted at left metacarpal vein
infusing well, afebrile, irritable, with passages of yellowish watery stool, vital signs are as follows (T-
36.2; P- 126bpm; R- 36cpm)
Past Health History:
RJ during his 4th month had convulsion due to high grade fever associated with asthma. He was
admitted in BRH and was confined for 5 days. He sometimes had cough and colds and her mother gave
her Tempra. He had no allergies to food nor medications. He had his immunization except for his
measles vaccine.
Family History:
RJ has 6 more siblings wherein three boys and three girls. The eldest is 19 years old and RJ is the
youngest. His eldest sister is the one taking care of RJ while their mother is away and working for their
family. His mother has no history of any disease while his father has a history of Asthma.
Personal History:
Patient RJ is the youngest in the family. He was delivered through Normal Spontaneous Delivery.
He was on bottled/formula feeding. He can consume 6-8 bottles a day. He sleeps 3-4 times a day. He
loves to eat boiled squash and mixed to steamed rice.
He is just starting to walk and most of the time, RJ plays on the ground and he sometimes put
anything on his mouth.
Social History:
Patient RJ being the youngest in their family is usually left in the house with her eldest sister. His
other siblings go to school. When his eldest sister is doing their household chores, RJ will just play alone
with his toys.
Their house is located in a congested area in Malitam. Garbage are not properly disposed. RJ
also loves to play around when other children are also playing.
8/2/2019 AGE for Case Pres.
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Psychological History:
RJ can talk few syllables like ma-ma and pa-pa. He started walking last month. His motor
development is appropriate with his age.
The major stressor in the family is that they are financially unstable. Also his mother wanted to
get home because of her job.
History of Present Illness:
Three days prior to admission, RJ experienced vomiting cup for 3 times associated with 2
loose stools.
Symptoms persisted until 1 day prior to admission when RJ had 2 episodes of loose stool and 4
episodes of vomiting. Her mother brought him to the Emergency Room in BRH. He was hydrated with
D5LR for 6hours and went home. Home medications was given (zinc and probiotics).
After few hours they went back to the hospital because of the same reason. Then few hours
prior to admission, patient still have loose stool (2x) and vomiting (3x), noted by the staff nurse to be
evaluated by the Resident on duty; thus RJ was admitted for further observation and proper
management.