Case presentation Presented by: Nor Aini binti Mohamad Mohd Izaan Hassan bin Haron Adam Safin bin Abdul Mutti
Demografic detail Patient’s initial : MSR R/N : SB00305473 Age : 4 y 10 m Gender : Boy Height : 106 cm Weight : 16 kg Ethnic group : Malay (Indonesian) DOA : 18 th December 2010 DOD : 21 st December 2010 Informant : Mother Address : Bandar Sri Damansara
Presenting Complaint MSR, a 4 years and 10 months old Indonesian boy was admitted to Sg Buloh Hospital on 18 th 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 complaint MSR 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 Review Impression : No abnormal finding except for GIT part System 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
Past medical/surgical history He 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 & Allergy He was on vitamin C given by his parents once in a day. No known allergy to any drug, food or medication.
Birth history Antenatal – 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 history He 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 history He 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 history Gross motor : he can skips on both feets, running, kicking and climbing Vision & 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 history He 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 contact His 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 history He 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 & family Economical 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.
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
Anthropometry Weight : 16kg Height : 106cm Impression : His weight is in 25 th centile and his height is in 50 th centile.
Vital signs Temperature : 36°C Blood pressure : 117/45 mmHg Pulse : 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 tenderness No sacral oedema Impression: 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 4 th 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 1 st and 2 nd 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 4 th 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 system No muscle wasting or hypertrophy on upper and lower limbs no bony deformity No signs of inflammation normal 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 18 th 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 gastroenteritis Point to support – diarrhea vomiting fever
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 dx Systemic infection Septicemia,meningitis Local infections resp tract infection otitis media,hep A, UTI Surgical disorder pyloric stenosis,intussusception, acute appendicitis,necrotising enterocolitis, Hirchsprung dz Metabolic d/order DKA
INVESTIGATION General 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
Definition Acute 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, 5 th edition) “ an increase in the frequency, fluidity and volume of stool compared to normal” (AMMCOP CPG)
Possible routes of transmission Person to person. Contaminated water and food. Animal to human. Multiple routes.
Clinical Manifestation Diarrhea. 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, 2 nd 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.
Treatment Oral rehydration therapy. Use to treat mild to moderate dehydration. Consist of : Sodium chloride (NaCl). Potassium chloride (KCl). Trisodium citrate. Glucose.
Continue… Mild ( < 5%). Give ORS. Feed normally. Moderate ( 5-10%). Give ORS. Small, frequent feeding. Assess hydration status 4 hourly. Fail ORS nasogastric tube.
Continue… Severe ( > 10%). Medical emergency. Intravenous fluid therapy. Resuscitation (normal saline). Correction of the deficit (0.45% saline, 4% dextrose). 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.