2 week
nd
Identifying data
RP
18 months old, male
Davao city
Chief Complaint
Hematochezia
• Informant
• Patient’s Mother
3 weeks PTA
Noted onset of loose stools
with streaks of fresh blood
History of
Present Patient was given Oral
illness rehydration salts
No consultation done
• 1 week PTA
• Still with recurrent loose stools
with fresh blood
History of • Sought consult with a private
physician and was prescribed
Present with Oral Metronidazole and
Oresol with good compliance
illness
• No laboratory were requested at
this time
• Few hrs PTA
• Noted increasing amounts
of fresh blood after every
History of bowel movement
Present
• Patient was noted to be
illness irritable
• Brought to the emergency
department
5 months PTC
Sought consult with a
Several episodes of private physician
loose bowel movement Diagnosed with
stools Amoebiasis and was given
Past Medical Oral Metronidazole
History No food and drug allergies
No Previous hospital admissions
• Mother had regular prenatal checkup at
the local health center
• No illnesses during pregnancy
• Born by G2P2 (2002) mother
Delivery • Delivered via NSVD at a lying in clinic
History • Term
• With good cry and suck
• No jaundice during neonatal period
• Breast fed up to 9 months then mixed
Nutritional bottle fed onwards
History • With good appetite and weight gain
2 months
• Looks at face
• Holds head up
• Reacts to sounds
6 months
• Grabs toy
Developmental • Rolls
Milestones 12 months
• First word “mama”
• Pulls up to stand
18 months
• Points at something
• More words
• Tries using a spoon
• At birth
• OPV
• Hepatitis B
Immunzations 1 dose BCG
3 doses DPT
3 doses MMR
HPN –
both sides
Family History (-) DM
(-) Cancer
• 2nd child (youngest)
• Mother is a housewife
Personal/Social • Father is a salesman
History • Both parents are non alcoholic beverage
drinkers and non smokers
• All family members living in one house and
in a single room
Review of Systems
(-) fever
(-) weight loss
(-) cough and colds
(-) cyanosis
(-) abdominal distention
(-) vomiting
(-) Hematemesis
(+) loose stools
(-)Melena
(+) Hematochezia
Physical Examination
• Awake, afebrile, NIRD
• Vital Signs
• BP- 90/60 mmHg
• PR- 115 bpm
• RR- 22 cpm
• Temp- 36.7 deg C
• Weight – 12.5 kgs
• Height- not taken
HEENT
• Normocephalic / atraumatic
• Anicteric sclerae
• Slightly pale palpebral conjunctivae
• No ear discharges
• Septum midline
• No coryza or discharges
• Supple neck
• No palpable lymph nodes
• No oral lesions
• Pinkish oral mucosa
Chest and Lungs
• Symmetrical chest expansion
• No lesions noted on chest wall
• Normal tactile fremitus
• Resonant on all lung fields
• No dullness
• No adventitious sounds noted
Cardiovascular
• Adynamic precordium
• PMI at 4th ICS MCL
• No heaves or thrills
• Distinct s1 and s2
• No murmurs
Abdomen
• Flabby
• Normoactive bowel sounds
• Non palpable liver edge
• No palpable masses noted
• No tenderness on deep and light palpation
Digital Rectal Examination
• No skin tags noted
• No fissures
• Good sphincteric tone
• No masses noted
• With fresh blood on examining finger
Neuro Examination
• Unremarkable
Salient Features
Impression?