HISTORY
Patient is a 15-year-old female who woke up on July 1 with nausea, vomiting, and diarrhea; all hit her 1 time about 9 o'clock. She threw throughout the day. Mom has some Phenergan, but it did not seem to slow her down. The diarrhea got bad. She got weaker. Mom said actually last night, she had encopresis where she had thrown on her bed, this was because she is so weak. Today, she felt better with the nausea, so she started trying to drink and then the vomiting started over and now she has throw up ______ and still having loose stools and diarrhea. She does baby-sit 1 kid she kept last week, the mom called her today and said that 1-year-old has diarrhea and has had all weekend, but it is getting better, so she is not sure if she got from there or where else, but she has not done anything else in summer except baby-sit. She has been in no camps. She said she felt cold, shivering. When she stands up, she feels like she is going to pass out, could not fairly get and sit up now. When I do, she gets lightheaded and feel like she is going to throw up and does not want to move.
Patient is a 15-year-old female who woke up on July 1 with nausea, vomiting, and diarrhea; all hit her 1 time about 9 o'clock. She threw throughout the day. Mom has some Phenergan, but it did not seem to slow her down. The diarrhea got bad. She got weaker. Mom said actually last night, she had encopresis where she had thrown on her bed, this was because she is so weak. Today, she felt better with the nausea, so she started trying to drink and then the vomiting started over and now she has throw up ______ and still having loose stools and diarrhea. She does baby-sit 1 kid she kept last week, the mom called her today and said that 1-year-old has diarrhea and has had all weekend, but it is getting better, so she is not sure if she got from there or where else, but she has not done anything else in summer except baby-sit. She has been in no camps. She said she felt cold, shivering. When she stands up, she feels like she is going to pass out, could not fairly get and sit up now. When I do, she gets lightheaded and feel like she is going to throw up and does not want to move.
PAST MEDICAL HISTORY
She has no known allergies.
She has been hospitalized once for Mycoplasma pneumoniae by myself 6
years ago. She has no chronic
illnesses. She is up to date on all
immunizations. She has been on Gardasil
vaccine and she has gotten the DTaP, so she is up to date on everything
current.
SOCIAL HISTORY
She is going to 10th grade and does well in school.
PHYSICAL EXAMINATION
GENERAL: When I see the
patient, she is afebrile.
VITAL SIGNS: Her
blood pressure is 100/50, pulse is read at 100.
Her mouth is dry. She keep trying
to lick her lips. She wants something to
drink, but when she does, she starts throwing up, so she was not given anything
at all.
ENT: Her TMs are
clear.
CHEST: Clear.
CARDIAC: Tachycardiac
rhythm, rate at 100, but is regular.
ABDOMEN: She has very
hyperactive bowel sounds. Pushing on
does not really sore, she says it cramps.
Start up to see if it could be orthostatic change, but she just got
lightheaded and felt like she has throws,
we just laid her back down.
Unable to get urine specimen.
ASSESSMENT
1. Acute
gastroenteritis.
2. Dehydration.
PLAN
At this time, put her in the hospital, started on IV D5
normal saline, ice chips. We did a CBC
and CMP. Also check stool for C and S
and rotavirus for keeping the kid that was sick over the weekend.
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