Gastroenteritis Case Study

1403 Words6 Pages
Student: Kirk McCalmon
ID: 00260578
Date Submitted: June 29, 2015
Semester: 05
Interview Conducted: June 23, 2015
Statement of Reliability: The patient is a 1 year old infant (W020) who is admitted at the request of their pediatrician for persistent vomiting and diarrhea. The patient's mother is the source of the history and considered to be a reliable source of information.
Chief Complaint/Concern: "I'm worried my child can't stop vomiting and using the toilet "
History of Present Illness: W020 is a 1 year old Afro-Caribbean female (W020) who is here today with her mother for a follow up visit due to a history of gastroenteritis for two days. W020 presented to Princess Margaret Emergency department on (6/11/2015) for persistent vomiting
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Bacterial gastroenteritis tends to develop as the result of poor hygiene. Thus, gastroenteritis could be likely diagnosis given the patients unsanitary living conditions.
2. Salmonellosis: Supported by complaints of diarrhea,vomiting, and poor hygiene (Stated in social history). Salmonella is commonly transmitted through contaminated food by unwashed hands. Since there are adequate water sources in the region where the patient lives this is a strong possibility.
3. Enterovirus: Enterovirus infections can occur any time during the year, but summer and early fall are the main enterovirus seasons. In addition, some of the patients symptoms supports and enterorviral infection such as the loose stool and vomiting.
4. Rotavirus: The symptoms are supported by the patients complaints of vomiting and diarrhea. Furthermore W020 is currently due for their rotarix immunization. The vaccination will help to safeguard against future rotavirus related infections the patient will encounter.
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Including a CBC/differential, urine culture, stool culture, and a lumbar puncture to obtain CSF for culture. This will be analyzed for enterovirus using PCR. Stool sample will be analyzed for C. diff toxins, and rotavirus. If the CBC/diff, csf, and urinalysis come back abnormal we will treat empirally with antibiotics (e.g. vancomycin) until the culture results are available. Problem 3 ( Due for Rotavirus immunization): Rotavirus is a common cause of Child will be scheduled for Rotarix administration. Rotarix is highly effective in preventing rotavirus related gastroenteritis and has been shown to be effective according to studies conducted in the united states. Also encouraging the mother to bring W020 in for regular checkups and make sure she is up date with her vaccinations to avoid any future complications. Problem 4-5 (Educating mother on proper hygiene and lack of access to clean drinking water): To provide instructions to mother on proper hygienic practices that can significantly reduced the risk of transmitting water-borne diseases. Also educating the patient on proper hand washing techniques and exploring areas within the local region to improving access to safe drinking water and access to sanitation

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