Karl V. Bolintiam

GENERAL INFORMATION• JB• 4/M• Filipino• Roman Catholic• Pasig City• Informant : mother• Good reliability 90%

CHIEF COMPLAINT

“Nilalagnat” (Fever of 4 days

duration)

4 Days PTA

FEVER

- intermittent- Tmax 38.0C- Paracetamol 3mL

VOMITING

- 1 episode- Non- bloody- non- bilious- non- projectile- Previously ingested

3 Days PTA

FEVER

- Persistence of feverVOMITING

- 1 episode- Same character

2 Days PTA

FEVER

- intermittentVOMITING

- 2 episodes- After intake of food

POOR ORAL INTAKE

- Poor appetite- Refused to eat or drink

1 Day PTA

FEVERABDOMINAL PAIN

- Generalized- Not localized- Unable to characterize- Irritability

(-) vomiting(-) dysuria(-) changes in bowel movement

Few Hours PTA

FEVER

ABDOMINAL PAIN

- Generalized- Not localized- Unable to characterize- Irritability

LOOSE WATERY STOOLS

- 3 episodes- non-bloody- Non mucoid- Foul smelling- yellowish

Past Medical History

• Unremarkable

Birth History

• Full term• NSD• 26 year old G1P1 (1001)• Birth weight 3.2 kg• Attended by OB• No complications

Immunization

(+)• DPT (3)• OPV (3)• Hep B (3)• BCG • Measles • MMR (2) • HiB (3)

(-)• Varicella• Pneumococcal• Influenza• Rotavirus• Hepatitis A

Nutritional History

• Breastfed until: 2 years• Formula: Bona kid• Weaning age: 6 months• No food allergies• Food preferences: cereals, banana• Current diet: rice, meat, vegetables, milk

Developmental History

• At par with age

FAMILY HISTORY

• (+) Asthma- maternal side• No other family members

with same signs and symptoms

32 30

STAKEHOLDER ANALYSIS

Stakeholder Interest in Issue

Role Level of Influence

Father Welfare of patient

Breadwinner High

Mother Welfare of patient

Caregiver High

PERSONAL-SOCIAL HISTORY

Bungalow houseGood ventilation

Drinking water from mineral

Garbage collected once a week

No smokers

No flood in the areaNo outbreaks

REVIEW OF SYSTEMS

General• (-) weight loss

Skin• (-) itchiness, color

changes, pigmentation, rashes, vasomotor chanes, photosensitivity, changes in hairs and nails

Eye• (-) sunken eyeballs• (-) blurring of vision,

redness, itchiness, pain, lacrimation

REVIEW OF SYSTEMS

Ear• (-) deafness, tinnitus,

discharge

Nose• (-) epistaxis, discharge,

obstruction, postnasal drip

Mouth and Throat• (-) bleeding gums,

sores, fissures, tongue abnormalities, dental caries, sore throat, lump sensation

REVIEW OF SYSTEMS

Cardiac• (-) orthopnea,

nocturnal dyspnea, syncope, edema

GU• (-) urgency, hesitancy,

dysuria, hematuria, nocturia,

Musculoskeletal• (-) joint stiffness,

pain, swelling, cramps, muscle pain, weakness, wasting

REVIEW OF SYSTEMS

Endocrine• (-) heat-cold

intolerance, polyuria, polydipsia

Hematopoietic• (-) abnormal

bleeding in other sites, bruising, anemia, adenopathy

Neurologic• (-) headache,

seizure, speech problems, mental change, head trauma

PHYSICAL EXAMINATION

PHYSICAL EXAMINATIONGENERAL APPEARANCE

Awake, alert, not in cardiorespiratory distress

VITAL SIGNS BP: 90/60, Temp: 38.9, HR: 102, RR: 28Wt: 15.2 kg (z=0) Ht: 102cm (z=0) BMI: z=0

SKIN (-) lesions, (-) hyperpigmentation, good skin retraction, (-) edema, (-) dryness of skin

HEENT Pink palpebral conjunctiva, Anicteric sclerae, (-) sunken eyeballs, EBRTL, (-) Lesions in the buccal mucosa, (+) dry oral mucosa, (-) TPC, (-) CLAD, non-enlarged thyroid

PHYSICAL EXAMINATIONCHEST Equal chest expansion, clear breath

sounds, no wheezes, rales, cracklesCARDIOVASCULAR

Adynamic precordium, no heaves thrills and lifts. Normal rate and regular rhythm, Good S1 and S2 sounds, no murmurs, full and equal pulses

PHYSICAL EXAMINATIONABDOMEN NABS, tympanic all quadrants, no

organomegaly, no direct or rebound tenderness(-) Rovsing’s, obturator, psoas sign(-) Murphy’s sign(-) CVA tenderness(-) obliteration of traube’s space

RECTAL Not examined

EXTREMITIES (-) peripheral cyanosis, warm extremities, CRT <2s

Salient features

Subjective• 4 days intermittent fever

(Tmax 38.0C)• Paracetamol temporary relief

• Vomiting 1-2 episodes/day in 3 days

• Poor oral intake• Abdominal pain• 3 episodes of loose watery

stools

Objective• 38.9 C• Pink conjunctiva, (-)

sunken eyeballs• (+) dry oral mucosa• Full and equal pulses• CRT < 2s• Warm extremities

PRIMARY WORKING IMPRESSION

Acute Gastroenteritis with no signs of dehydration

DIFFERENTIAL DIAGNOSIS

• Dengue fever• Typhoid fever• Systemic viral illness• UTI

COURSE IN THE WARDS

DAY 1 of Hospitalization

Subjective• - No appetite • - No intake of food• - Still with abdominal

pain• - No vomiting• - No dysuria

Objective • T 38.1 C• 90/60• HR 102, RR 28• Not in distress• Non sunken eyeballs,

pink conjunctivae, warm extremities, CRT<2

• Soft abdomen

Assessment• Acute gastroenteritis

Plan• Stool/ vomitus charting• Monitor input and

output• Zinc 20mg/ 5mL (5mL)• Bacillus (erceflor) 1 vial

2x a day• Dengue NS1• Urinalysis• Stool exam

DAY 2 of Hospitalization

Subjective• Day 4 of illness• No intake of food• (-) Abdominal pain• No urine output for 8

hours

Objective • T 38.5 C• 100/60• HR 128, RR 24• Not in distress• Non sunken eyeballs,

hyperemic tonsils• Hyperactive bowel sounds• Warm extremities• Non-distended bladder• Soft abdomen

Assessment• Acute gastroenteritis

Plan• Continue IV hydration• Fast drip with PNSS 150

mL

DAY 3 of Hospitalization

Subjective• Day 5 of illness• Fecalysis result:

brown/watery/-mucus/- blood/ no ova or parasite/ - RBC/ WBC 0-2

• 2x stools with particles• No vomiting• Improving appetite

Objective • T 37.4 C• 90/60• HR 120, RR 22• Non sunken eyeballs• Pink conjunctivae, clear

breath sounds• Normoactive bowel

sounds• Soft abdomen

Assessment• Acute gastroenteritis

Plan• Continue trial of

feeding• MGH

DISCUSSION

DIARRHEA

• Passage of unusually loose or watery stools• At least 3 times in a 24 hour period• Consistency is most important

CLINICAL TYPES

Acute watery

• Main danger: dehydration• Weight loss

Acute bloody

• Dysentery• Main dangers: damage of the intestinal mucosa, sepsis, malnutrition

persistent

• Lasts 14 days or longer• Main danger: malnutrition and serious non-intestinal infection

With severe malnutrition

• Marasmus or kwashiorkor• Main dangers: severe systemic infection, dehydration, heart failure, and vitamin and

mineral deficiency

Assessment of dehydration

A B CWell, alert

NormalDrinks normally,

not thirsty

Restless, irritableSunken eyeballsThirsty, drinks

eagerly

Lethargic or unconscious

Sunken eyeballsDrinks poorly or unable to drink

Skin pinch Goes back quickly Goes back slowly Goes back very slowly

Decide NO signs of dehydration

Some dehydration Severe dehydration

Treat Home therapyIncrease fluids

Inc nutrition/feeding

Zinc 10-20 mg/day for 10-14

days6x a day feeding

Oral rehydration therapy (wt x

75mL)Zinc (after 4 hr

rehydration period)

100 mL/kg ringer’s lactate

TREATMENT PLAN A

• Home therapy to prevent dehydration and malnutrition1. Give more fluids than usual2. Supplemental zinc• 10-20 mg everyday for 10-14 days

3. Continue to feed the child• Small frequent feedings

4. Consult if there are signs of dehydration

Assessment of dehydration

A B CWell, alert

NormalDrinks normally,

not thirsty

Restless, irritableSunken eyeballsThirsty, drinks

eagerly

Lethargic or unconscious

Sunken eyeballsDrinks poorly or unable to drink

Skin pinch Goes back quickly Goes back slowly Goes back very slowly

Decide NO signs of dehydration

Some dehydration Severe dehydration

Treat Home therapyIncrease fluids

Inc nutrition/feeding

Zinc 10-20 mg/day for 10-14

days6x a day feeding

Oral rehydration therapy (wt x

75mL)Zinc (after 4 hr

rehydration period)

100 mL/kg ringer’s lactate

TREATMENT PLAN B

• Oral rehydration therapy for children with some dehydration1. Wt in kg x 75 mL = approx amt of ORS2. do not use feeding bottles3. Monitor progress4. Continue to breastfeed5. Zinc- following 4 hour rehydration period

Assessment of dehydration

A B CWell, alert

NormalDrinks normally,

not thirsty

Restless, irritableSunken eyeballsThirsty, drinks

eagerly

Lethargic or unconscious

Sunken eyeballsDrinks poorly or unable to drink

Skin pinch Goes back quickly Goes back slowly Goes back very slowly

Decide NO signs of dehydration

Some dehydration Severe dehydration

Treat Home therapyIncrease fluids

Inc nutrition/feeding

Zinc 10-20 mg/day for 10-14

days6x a day feeding

Oral rehydration therapy (wt x

75mL)Zinc (after 4 hr

rehydration period)

100 mL/kg ringer’s lactate

TREATMENT PLAN C

Age 30 mL/kg 70 mL/kg<12mo 1 hour 5 hours

> 1 year old 30 minutes 2 ½ hours

• For patients with severe dehydration• Reassess patient every 1-2 hours, if patient is not improving, give IV drip

100 mL / kg Ringer’s Lactate

Electrolyte disturbances

• Hypernatremia• Na > 150 = thirst out of proportion to signs of dehydration• Na > 165 = convulsions

• Hyonatremia• Na < 130mmol/L• Lethargy, seizures

• Hypokalemia• K < 3mmol/L• Muscle weakness, paralytic ileus, impaired kidney fcn,

cardiac arrhythmia

CHOLERA

• Occurs in large epidemics that involve both children and adults

• Voluminus watery diarrhea severe dehydration with hypovolemic shock

• Antibiotics may shorten illness duration

ACUTE BLOODY DIARRHEA

• Dysentery• Shigella• Ciprofloxacin 3 days or 5 days with another oral

antimicrobial• Seen again after 2 days:• Initially dehydrated, less than 1 year old, had measles

within past 6 weeks, not getting better

AMOEBIASIS

• Unusual cause of bloody diarrhea• Trophozoites of E histolytica containing red blood cells • or two different antimicrobials for shigella does not

provide relief

PERSISTENT DIARRHEA

• Diarrhea with or without blood what begins acutely and lasts at least 14 days

• Breastfeeding prevents persistent diarrhea