What is the diagnosis and recommended treatment for an 11-year-old male patient with 3 days of soft stools, body aches, cough, and fecalysis showing RBC 1-4, WBC 5-7, and +3 bacteria?

Diagnosis and Treatment for 11-Year-Old Male with Acute Gastroenteritis

Medical Assessment/Diagnosis

This patient has Acute Bacterial Gastroenteritis with mild dehydration. The fecalysis showing bacteria +3, WBC 5-7, and RBC 1-4 indicates bacterial infection with mild inflammatory response, while the 3-day history of loose stools, body aches, and rhinorrhea are consistent with acute infectious gastroenteritis 1, 2.

Clinical Reasoning:

• The presence of bacteria +3 on fecalysis with elevated WBC (5-7) suggests bacterial etiology rather than viral gastroenteritis 3
• The absence of high fever, bloody diarrhea, or severe abdominal pain indicates non-severe disease that does not require specific antimicrobial therapy 3
• The concurrent upper respiratory symptoms (rhinorrhea) and body aches suggest a viral component or concurrent viral illness 2
• The previously given cefuroxime was unnecessary and should be discontinued - empiric antibiotics are not recommended for acute watery diarrhea without fever, bloody stools, or signs of severe illness 1, 4

Treatment Plan/Recommendations

Primary Management - Rehydration:

• Oral rehydration solution (ORS) is the cornerstone of treatment 1, 5
• Instruct patient to drink ORS frequently in small amounts to replace ongoing losses 1
• Continue age-appropriate regular diet immediately - no dietary restrictions needed 1, 5

Symptomatic Treatment (PhilHealth Konsulta Formulary):

1. For loose stools and hydration:

• Oresol (Oral Rehydration Salt) - 1 sachet dissolved in 1 liter of water, drink frequently throughout the day until diarrhea resolves
• Dispense: 5 sachets for 3-5 days duration
• Cost: ~₱50-75

2. For body aches/myalgia:

• Paracetamol 500mg - 1 tablet every 6 hours as needed for body aches
• Dispense: 12 tablets for 3 days
• Cost: ~₱12-24

3. For rhinorrhea (if bothersome):

• Cetirizine 10mg - 1 tablet once daily at bedtime
• Dispense: 3 tablets for 3 days
• Cost: ~₱15-30

Total estimated cost: ₱77-129 (well within ₱300 budget)

Important Instructions:

• STOP cefuroxime immediately - antibiotics are not indicated for this non-severe case and may prolong symptoms or cause adverse effects 1, 4
• Continue ambroxol only if productive cough persists (not typically needed for simple rhinorrhea)
• Return immediately if develops high fever (>38.5°C), bloody stools, severe abdominal pain, signs of dehydration (decreased urination, extreme thirst, lethargy), or symptoms worsen 3
• Maintain good hand hygiene to prevent transmission 1

Follow-up:

• Symptoms should improve within 3-5 days with supportive care alone 2, 4
• If diarrhea persists beyond 7 days, return for re-evaluation to rule out parasitic infection or other causes 3, 1

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Medical Certificate

This certifies that patient has been seen and examined today with the diagnosis of: Acute Bacterial Gastroenteritis, mild

Recommendation: Home rest with oral rehydration therapy and symptomatic treatment. May return to school after 24 hours if symptoms improve and no fever. Fit to return to school on [date 2 days from consultation] provided symptoms have resolved.

This medical certificate is issued upon the request of the patient for: school absence/return to school clearance

Key Clinical Pitfalls to Avoid:

• Do not continue unnecessary antibiotics - the cefuroxime provides no benefit for non-severe bacterial gastroenteritis and increases risk of antibiotic resistance and C. difficile infection 1, 4
• Do not use antimotility agents (loperamide) in children under 18 years - contraindicated due to risk of complications 1, 5
• Do not withhold food - early refeeding improves outcomes 1, 5
• Do not assume all bacteria on fecalysis require antibiotics - most bacterial gastroenteritis is self-limited 3, 4, 6