Case presentation

Presented by: Nor Aini binti MohamadMohd Izaan Hassan bin HaronAdam Safin bin Abdul Mutti

Demografic detailPatient’s initial : MSRR/N : SB00305473Age : 4 y 10 mGender : BoyHeight : 106 cmWeight : 16 kg Ethnic group : Malay (Indonesian)DOA : 18th December 2010 DOD : 21st December 2010Informant : MotherAddress : Bandar Sri Damansara

Presenting ComplaintMSR, a 4 years and 10 months old Indonesian

boy was admitted to Sg Buloh Hospital on 18th December 2010 at 11.00 pm due to severe diarrhea 2 days prior to admission associated with fever and vomiting on the day of admisssion.

History of presenting complaintMSR was well until 2 days prior to admission

when he started to develop diarrhea. It started at 2.00 am and it was sudden in onset and occurred about 8-10 times per day. The diarrhea was watery in nature, yellowish to brown in colour with no blood stained. His mother had to wear him diapers to reduce his frequency to go to the toilets. Since then, he had loss of appetite and only ate little amount of foods and drinks. There was no recent history of taking outside food or travelling.

On Saturday morning which was 2 days after diarrhea occurred, his mother brought him to the clinic and the doctor prescribed him Oral Rehydration Salt(ORS). However, the problem was not resolved.

His fever and vomiting was started a few hours after he was brought to the clinic. His mother measured the temperature at home and it was 39.2 (high grade fever) with no rigor. His mother said that there was no rash or joint pain and no episode of fit since he had the fever. No cough or runny nose.

The vomiting was started on the same time with fever. It occurred once and non-projectile. His mother described the amount of vomitous was about half of cup, contained fluid but no blood or bilious with slight offensive smell. There was no history of changing formula milk.

His mother said that MSR was appeared lethargic and less active than usual during that period. She brought him back to the same clinic at the evening on the same day. The doctor gave PCM per rectally and antiemetic drugs to reduce his fever and vomiting. He was then referred to HSB and his parents brought him to ED at 8.30pm and was admitted to ward 8C at 11.oopm.

Systemic ReviewSystem Complaints

CVS No pedal edema, no cyanosis

Resp No SOB, no cough, no hemoptysis

Genitourinary Normal urine output, no hematuria

CNS No LOC, no drowsiness, no blurring vision, no altered speech, no headache

ENT No runny nose, no ear discharge, no feeding difficulty, no dysphagia

MSK No abnormal movement, no joint swelling, no joint pain

Endocrine No tremor, no heat intolerance

Hematological No gum bleeding or epistaxis

Impression : No abnormal finding except for GIT part

Past medical/surgical historyHe was once admitted to Hospital Selayang

at the age of 2 years old due to shortness of breath. He was suspected to have asthma but after the first attack, he did not have SOB anymore.

Drug history & AllergyHe was on vitamin C given by his parents

once in a day.No known allergy to any drug, food or

medication.

Birth historyAntenatal – his mother developed GDM and

was managed with insulin therapy during her pregnancy.

Natal – he was born full term at HBKL, via ELLSCS due to DM, birth weight was about 2.6 kg and cried right after birth.

Postnatal – his mother was informed that MSR developed respiratory problems and was admitted for 6 days in NICU. He developed mild jaundice after 4 days of life for 1 week.

Feeding historyHe was exclusively breastfeed until 3 months

and started to mix with infant formula. Start weaning at the age of 6 months and wasv breastfeed up to 2 years of age. Now, he was on family diet.

Immunization historyHe received last immunization at 1 year and

6 months old. No postponed vaccination or complication after vaccination. The latest immunization was DTaP, IPV and Hib.

Impression : Immunization is up to his age

Developmental historyGross motor : he can skips on both feets,

running, kicking and climbingVision & fine motor : he was able to draw

straight line, circle and cross line without seeing how it is done. He can draw recognisable features such as cartoon and and ice-cream.

Speech & language : He knows his age, names 4 colours, he can talks constantly in 4-5 words and understand command.

Personal & social : able to dress and undress alone, plays with other friends.

Impression : Development milestones is corresponding to his chronological age

Family historyHe is the youngest out of three siblings. The

first and second siblings aged 18 and 8 years old respectively. Both are females and well. His parents were well and there was no history of chronic illness such as asthma, HTN, DM or any malignancy run in his family.

History of contactHis mother claimed that the children in same

kindergarten with MSR did not have any symptoms like him.

No history of contact in this patient.

Social and environmental historyHe was the youngest child out of three siblings.

Currently entered kindergarten and performed well in class. His father, 48 y/o works as contractor worker and his mother, 38 y/o works as a cleaner. Total gross monthly income is about RM1000.

They live in Bandar Sri Damansara in a flat house, level 5, with good basic amenities. His older sister age 18 y/o lived in Jawa Timur, Indonesia and currently continue studying in IT course. His second sister age 8 years old was taken cared by their neighbour since MSR is on admission.

Effect of illness to the pt & familyEconomical effect is the most common

problem in this case. As they are not Malaysian, they need to pay more than our people pay for hospital’s bill. Their total income also will be affected since his mother need to take leave from the workplace to take care of him.

Mohd Izaan Hassan bin Haron2008402242

General condition MSR was lying comfortably in supine

position, supported by 1 pillow. -He was conscious, alert and responsive

to people. -Not in pain

-Nutritional and hydration status was good

AnthropometryWeight : 16kgHeight : 106cmImpression : His weight is in 25th

centile and his height is in 50th centile.

Vital signsTemperature : 36°CBlood pressure : 117/45 mmHgPulse : 98 beat per

minute, normal volume, normal rhythm

Respiratory rate : 31 breathe per minute

Oxygen saturation : 100%Impression : He is currently

stable.

Examination for Hydration status

tongue and mucous membranes in the oral cavity were moist

Normal skin turgor. Capillary refill time was less than 2

seconds Impression: His hydration status was

good.

Examination of Face, Head & Neck, Limbs

Appearance : no abnormality detected Hands : no abnormality detected Pallor : no pallor Cyanosis : no cyanosis Oral cavity : Good oral hygiene, moist mucous membrane,

pink tongue Eyes : no pallor, jaundice, discharge, sunken eyes ENT : no ear and nose discharge Shape of head : Normal head shape Neck : no thyroid enlargement, abnormal pulsation Hair : no abnormality detected Extremities : no cyanosis at nail bed, finger clubbing,

palmar erythema, capillary refill time is less than two seconds,

Oedema : no oedema Impression : no abnormality detected

Examination of back

No spinal deformities such as scoliosis, lordosis and kyphosis

no tendernessNo sacral oedemaImpression: No abnormality detected

Examination of lymph nodes

no palpable lymph nodes in cervical, occipital, axillary and inguinal areas

Impression: No abnormality detected

Cardio-vascular system

On inspection, his chest moves symmetrically with respiration. There was no chest wall deformity, no scar, no dilated veins, no precordial bulge, no sign of respiratory distress and no visible pulsation noted.

On palpation, apex beat was felt at 4th intercostals space, mid-clavicular line. There was no left parasternal heaves and no thrills at left sternal edge, pulmonary area and aortic area.

 On auscultation,

normal 1st and 2nd heart sound was heard. There was no additional heart sound or murmur.

 Impression: No abnormal findings

Respiratory system

On inspection,the chest moves symmetrically with respiration on both sides. There was no suprasternal, intercostals and subcostal recession. There was no chest deformity and no scar seen. The chest was not hyperinflated.

On palpation, the trachea is centrally located and chest expansion was symmetrical on both sides. The apex beat was located at 4th intercostals space, mid-clavicular line. Normal vocal fremitus was noted

On percussion,both sides of his mid clavicular, mid axillary, and scapular line segments of lungs were resonance. There was normal liver and cardiac dullness.

On auscultation, the air entry was adequate on both sides of the lung. Normal vesicular breath sound was heard. There were no added sounds heard.

Impression: No abnormal findings

Abdominal examination

On inspection, his abdomen was symmetrically distended and moves with respiration. The umbilicus was centrally located and inverted. There was no abnormal scar, no dilated vein, no visible pulsation and peristalsis noted.

On light palpitation, his abdomen was soft and non tender. On deep palpation, there was no tenderness, no mass felt and no hepatospleenomegaly. Both his kidneys were not ballotable

 On percussion, there was no dullness On auscultation, normal bowel sound present with

no renal bruit. Impression: no abnormality detected

Musculoskeletal systemNo muscle wasting or hypertrophy

on upper and lower limbsno bony deformityNo signs of inflammationnormal movement of joint

Impression: No abnormal findings.

Nervous system

Higher function: -Mental status: good-Speech: good

Cranial nerves: cranial nerves were intact.Motor function: Muscle bulk and muscle tone was

normal. Muscle power for all extremities grading 5/5. Biceps, triceps, supinator, knee, and ankle reflexes were present. Plantar response was normal with negative Babinski’s sign. The abdominal reflex was also normal.

Sensory functions: A) Sensory: Normal sensation to touch, pain, temperature, vibration and joint position sense.

B) Signs of meningeal irritation: No neck stiffness with negative Brudzinski’s sign and Kernig’s sign.

SUMMARY

MSR, a 4 years and 10 months old Indonesian boy was admitted to Sg Buloh Hospital on 18th December 2010 at 11.00 pm due to severe diarrhea 2 days prior to admission associated with fever and vomiting on the day of admisssion. On physical examination, there was no abnormality detected.

Provisional diagnosis

Acute gastroenteritisPoint to support – diarrhea

vomitingfever

DIFFERENTIAL DIAGNOSIS

Points to support

Points to against

Small bowel obstruction (intussusception)

-Vomiting -Diarrhea

-The vomitous was not bile-stained-The abdominal pain was not severe- No blood stained stool

Acute appendicitis

-vomiting-abdominal pain

Usually not associated with diarrhea

Differential dxSystemic infection

Septicemia,meningitisLocal infections

resp tract infectionotitis media,hep A, UTI

Surgical disorderpyloric stenosis,intussusception, acute appendicitis,necrotising enterocolitis, Hirchsprung dz

Metabolic d/orderDKA

INVESTIGATIONGeneral Investigations

full blood count

Impression: no abnormality detected

Result Normal range Remarks

WBC 12.84 4.5-13.5 x 10*9/L Normal

Hb 12.2 11.5-14.5 g/dL Normal

Plt 432 150-4– x 10*3 uL normal

Haematocrit

37.1 37-45% Normal

Renal profile

Impression: No abnormality detected

Result Normal range Remarks

Urea 3.5 1.7-6.4 mmol/L Normal

Sodium 138 135-150 mmol/L Normal

Potassium 3.80 3.5-5 mmol/L Normal

Chloride 102.0 98.0-107.0 mmol/L Normal

Creatinine 52.6 44-88 mmol/L Normal

FINAL DIAGNOSISAcute Gastroenteritis

Adam Safin bin Abdul Mutti2008402544

DefinitionAcute Gastroenteritis :

“diarrheal disease of rapid onset, with or without accompanying symptoms, signs, such as nausea, vomiting, fever, or abdominal pain.”

(American Academy of Paediatrics)

Continue…Diarrhea :

“ abnormal frequency and liquidity of fecal discharges”

(Nelson Pediatrics, 5th edition)

“an increase in the frequency, fluidity and volume of stool compared to normal”

(AMMCOP CPG)

Possible routes of transmissionPerson to person.Contaminated water and food.Animal to human.Multiple routes.

What organism cause AGE???Acute Gastroenteritis

Viruses.

•Rotavirus (most common).•Calicivirus.•Astrovirus.

Bacteria•Campylobacter jejuni.•Salmonella.•Shigella.•E.coli.•Clostridium difficile.

Parasites.•Entamoeba histolytica.•Giardia lamblia.

Clinical ManifestationDiarrhea.Fever.Reduce oral intake.Abdominal pain.Sign and symptoms of dehydration.

Indication of admission.Need for intravenous therapy.Uncertainty of diagnosis.Patient factors (e.g : worsening of symptoms,

young age).Caregivers not able to provide adequate care

at home.Social or logistic concerns.(Paediatric Protocol for Malaysian Hospital, 2nd

edition)

What investigation should be done???Full blood count.Urea and electrolytes.Urinalysis.Stool culture.Blood culture (typhoid fever).

Sign and symptom of dehydration.Reduced level of consciousness.Sunken fontanelle.Dry mucous membrane.Sunken eye and tearless.Reduced skin turgority.Tachypnoea, tachycardia, hypotension.Prolonged CRT ( > 2 seconds)

Sunken fontanelle

Eyes sunken and tearless Reduced skin turgor

Management.To correct the dehydration in patient.

As the main complication of AGE is due to dehydration and its complication.

Thus, assessment of dehydration is very important.

Mild : < 5% dehydration Moderate : 5-10% dehydration. Severe : > 10% dehydration.

TreatmentOral rehydration therapy.

Use to treat mild to moderate dehydration.Consist of :

i. Sodium chloride (NaCl).ii. Potassium chloride (KCl).iii. Trisodium citrate.iv. Glucose.

Continue…i. Mild ( < 5%).

Give ORS.Feed normally.

ii. Moderate ( 5-10%).Give ORS.Small, frequent feeding.Assess hydration status 4 hourly.Fail ORS nasogastric tube.

Continue…iii. Severe ( > 10%).

Medical emergency.Intravenous fluid therapy.a.Resuscitation (normal saline).b.Correction of the deficit (0.45% saline, 4%

dextrose).c.Maintenance (0.18% saline, 4.3% dextrose).

Feeding after AGE???Should be started soon.Avoid fatty foods and foods high in sugars.

Issue???Use of anti-emetics and anti-diarrheal

drugs???Antibiotics???

Type of dehydration

Dehydration.

Isonatraemic.

•Sodium losses = water losses.

Hyponatraemic.•Sodium losses > water loses.•Shift of water to intracellular compartment.•Can lead to convulsion.

Hypernatraemic.•Water losses > sodium losses.•Shift of water to extracellular compartment.•Difficult to recognise clinically.•Multiple,small cerebral hemorrhages.