Reference no: EM133295672

Case Scenario: Infant with Acute Gastroenteritis, Mild Dehydration

During physical examination, you noticed that JAC is a bit weak and irritable. He is always crying and doesn't drink much milk. Upon interview with the mother, she verbalized "Jac won't drink milk anymore, then if he drinks it he will throw up immediately. I'm really worried that we just got admitted " He is warm to touch with a body temperature of 38.5 °C with occasional complaints of abdominal pain. His eyes appear a bit sunken. He weighs 9 kgs and likes to sleep a lot. When checking his vital signs, his results where HR - 100bpm, RR 34cpm, BP of 100/60mmHg. His head appears to be asymmetric. His eyes are normal, pupils equally round and reactive to light. His ears a symmetrical with clear tympanic membranes and clear bilateral canals. His nose is located at the midline of the face with no nasal septal deviation. A little bit of nasal flaring is noted. Pharyngeal mucosa is pink and moist. His mouth is a bit dry and cracked. With central and lateral incisors appearing on the top and bottom of his mouth. His oropharynges are pink and moist, no erythema noted, no tonsillar enlargement noted. Neck is located at the midline of the body and no tracheal deviation noted. His heart rate is around 100bpmwith regular rhythm. Heart sounds audible with clear S1 and S2 sounds. No murmur, rubs and gallops noted. Chest appears to be normal with respiratory rate of 34bpm. He appears to be breathing a bit faster than normal, nasal flaring is noted and use of accessory muscles is apparent. His O2 sat is 94% with slightly cyanotic skin color. His abdomen is a little bulging, soft and non-tender with 40 bowel sounds heard per minute. He is able to move his arms and legs and is able to stand with support. He is conscious and irritable but a bit sleepy.