Medical Assessment and Management
Diagnosis
Acute Bacterial Gastroenteritis with Upper Respiratory Tract Infection
The fecalysis showing bacteria +3 with elevated WBC (5-7) and RBC (1-4) indicates bacterial infection of the gastrointestinal tract 1. The combination of soft stools for 3 days, body aches, and cough suggests concurrent viral upper respiratory infection with bacterial gastroenteritis 2.
Clinical Assessment
Hydration Status: Assess for signs of dehydration (dry mucous membranes, decreased skin turgor, sunken eyes) 2. Based on presentation, patient appears to have mild dehydration given 3-day history.
Key Clinical Features:
- Duration: 3 days of loose stools
- Systemic symptoms: Body aches, rhinorrhea
- Laboratory: Fecal WBC 5-7, RBC 1-4, Bacteria +3 indicating inflammatory diarrhea 1
Treatment Plan
Rehydration (Priority)
- Oral Rehydration Solution (ORS): 50 mL/kg over 2-4 hours for mild dehydration 2
- Resume normal age-appropriate diet immediately after rehydration 2
- Avoid fatty, spicy foods temporarily 2
Antimicrobial Therapy
Current regimen of cefuroxime is appropriate but needs reassessment 1. For bacterial gastroenteritis with inflammatory features (elevated fecal WBC, bacteria +3), antibiotic therapy is indicated 1.
However, given PhilHealth budget constraint (<300 pesos) and formulary limitations:
Recommended Medication:
- Cotrimoxazole (Trimethoprim-Sulfamethoxazole) suspension
- Dose: 8-10 mg/kg/day (based on trimethoprim component) divided BID
- For 11-year-old (estimated 30-35 kg): 240 mg (5 mL) twice daily
- Dispense: 100 mL bottle
- Duration: 5 days
- Cost-effective alternative for bacterial gastroenteritis 1
Symptomatic Treatment:
- Ambroxol syrup (continue current prescription)
- Dose: 15 mg (5 mL) three times daily
- Dispense: 60 mL bottle
- Duration: 5 days
- For cough/rhinorrhea symptoms
Important Caveats
- Loperamide is CONTRAINDICATED in children <18 years with acute diarrhea 2
- Monitor for worsening symptoms: high fever, bloody stools, severe abdominal pain 1
- If symptoms worsen or persist beyond 5 days, return for re-evaluation 1
Requested Tests/Recommendations
- No additional tests needed at this time 1, 2
- Continue oral hydration
- Monitor for signs of dehydration
- Return if: bloody stools develop, high fever (>39°C), severe abdominal pain, or no improvement in 48-72 hours 1
Medical Certificate
This certifies that patient has been seen and examined today with the diagnosis of: Acute Bacterial Gastroenteritis with Upper Respiratory Tract Infection
And recommendation of: Oral rehydration, antibiotic therapy with Cotrimoxazole for 5 days, symptomatic treatment with Ambroxol, rest, and follow-up if symptoms worsen or persist beyond 5 days.
This medical certificate is issued upon the request of the patient for: School excuse/medical documentation
Patient/Parent Education
Explanation of Condition: Ang inyong anak ay may impeksyon sa tiyan na dulot ng bakterya, kasama ng sipon at ubo. Ang bacteria sa dumi at white blood cells sa laboratory ay nagpapakita ng bacterial infection. Ang pinakamahalagang gamot ay ang oral rehydration solution (ORS) upang maiwasan ang dehydration 2. Ang antibiotic (Cotrimoxazole) ay tutulong labanan ang bakterya sa tiyan 1. Ang Ambroxol ay para sa ubo. Mahalaga ang pagbalik kung lumala ang sintomas o may dugo sa dumi 1.
Total Estimated Cost: Approximately 250-280 pesos (within PhilHealth budget)