wards. case 2 and poorly done

the importance of obtaining a patient's complete history and proper physical exam cannot be overemphasized. all details must be ascertained. patient's history alone can give you more or less a clinical impression, 60% of the time.

in the ward today, i was assigned to a patient whose chief complaint is lethargy. he was brought in the emergency department at 7pm last night. nine hours PTA (10:00 AM, June 25, 2008), the patient had an episode of vomiting and simultaneously with diarrhea. Quantity of vomitus is about 3 cups which consisted of ingested food the night before (generally white in color). His stools were greenish and watery, with traces of undigested vegetable fibers, without blood or mucus. Throughout the day, he vomited thrice. In the second and third episodes, vomitus were about a cup that were mainly clear liquid. his last measl was on the night before the admission which included rice, sinigang na baboy and red egg with tomatoes. he was not able to eat due to the vomiting bouts. he self-medicated with imodium (loperamide). he later then became lethargic and weak which prompted him to seek consult.

this is a GI case. simple lang naman eh... but i sucked in the abdominal exam... particularly in percussing. or was it dull? i feel bad that i still cannot do percussion perfectly. when i practice at home, i hear tympanitic sounds.... in my patient...the four quadrants were dull or rather, seemed dull.. liver cannot be assessed properly because it's supposed to be dull. but i pressumed (assumed) that liver is about 10cm... haha, imbento...

as i was saying, history alone can give us a clinical impression... pampalubag loob... pero was i able to do a detailed account of the events? NO! was doing the written report realizing that i failed to inquire about the other food or liquids ingested... lunch time. or if he drank water from somewhere or waht... ay nako naman... i did ask if the other members of the family were having the same symptoms. none of them were; he was the only one who ate red egg, so i'm guessing it's bugok.

i'll just go visit the patient first thing in the morning before my presentation...

assessment as of the moment:
hypovolemic shock secondary to dehydration from diarrhea and vomiting...