DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
FINAL DIAGNOSIS: Dehydration secondary to acute gastroenteritis.
HISTORY OF PRESENT ILLNESS: This is a (XX)-month-old male in good health until four days prior to admission when he developed a fever of 101-102 for two to three days, initially started with some congestion and coughing. By the third day, he began to have diarrhea, at least five to six times per day, and then began to vomit the following day, which was one day prior to admission, at least two or three times per day. However, both vomiting and diarrhea persisted into the day of admission and his fever persisted. At that point, he began to refuse p.o. fluids, and his urine output was also decreasing. He was then sent to the emergency room for further management of dehydration.
PAST MEDICAL HISTORY: Unremarkable.
SOCIAL HISTORY: He lives at home with parents and twin brothers, who are not sick. Only sick contacts were the grandparents, who had some diarrhea.
PHYSICAL EXAMINATION: GENERAL: On admission, asleep in bed but easily aroused. VITAL SIGNS: Temperature 100.4, pulse 132, respirations 38, O2 saturation 97%, and weight 11.6 kilograms. HEENT: His mucous membrane was dry but still had good capillary refill. Bilateral TMs were clear. Nose was clear. Pharynx was moist but not red. NECK: Supple. HEART: Regular without murmur. LUNGS: Clear. ABDOMEN: Soft with bowel sounds, nontender, nondistended. EXTREMITIES: Normal.
LABORATORY DATA: On admission, sodium 140, potassium 4.2, chloride 106, CO2 of 16, BUN 15, creatinine 0.4, glucose 118, white count 5500, hemoglobin 13.6, hematocrit 40, platelets 246,000, 52 polys, 38 lymphs, 9 monos. Blood culture was done, which was subsequently negative.
HOSPITAL COURSE: Prior to hospitalization, in the emergency room, he received two boluses of IV fluids and Zofran. However, he continued to have diarrhea and was then admitted with a CO2 of 16. His fever, however, defervesced quickly, and the following day, T-max was 100.6. He started tolerating small sips of fluids, including iced tea and Gatorade. He initially tolerated some bananas and bread but continued to have diarrhea, at least seven times a day, but his hydration was maintained with IV fluids at one and a half maintenance, but because of the diarrhea, his CO2 did drop to 14 with a sodium of 138, potassium 4.6, BUN of 5, creatinine 0.3, and glucose 126.
He was continued on IV fluids and a bland diet. However, by the second day, he did have pizza and began vomiting again, at least two times, but his diarrhea became small in amount and even at the end of the day became somewhat pasty. Initially, he was heplocked, but with vomiting, his IV fluids were restarted at one and a half maintenance and was decreased to one maintenance. The following day, he did much better on bread, cereals, tolerating all p.o., drank as much as 26 ounces in a day, and his bowel movement became small, loose, but never filled up the diaper and had decrease in frequency to four times. He has had no further vomiting since eating pizza. He slept well through the night and was drinking well on the morning of discharge, taking at least 3 to 4 ounces of Gatorade, eating half a bowl of cereals and half a muffin.
IV fluids were discontinued in the evening prior to admission, and he appeared to be well hydrated in the morning with tears and wet diapers. He was then discharged with instructions to advance his diet slowly to bread, crackers, bananas, potato, soups, rice, and pasta and by the following day some bland meats. He was to remain off any dairy products until his diarrhea has completely resolved. He was encouraged to continue to drink well, especially Gatorade and Pedialyte, and advance to fluids like juice and soups.
The parents are to call if vomiting returns, diarrhea worsens or not taking p.o. fluid well. He is to be followed up in two days. His electrolytes were also repeated prior to discharge and sodium was 137, potassium 4.3, chloride 105, CO2 of 21, BUN 2, creatinine 0.3, and glucose 96. His last urinalysis showed a urine specific gravity of 1.005 with no ketones. Stool cultures were attempted but none successful with just small amounts.
