lecture on diarrhea for medical students

1. A 2 years old boy presented in emergency with fever,
vomiting & loose stools for 2 days. He is passing scanty
urine for last 12 hrs. O/E, pulse = 130/min & is of low
volume. BP = 70/50 mm Hg.
What 4 clinical signs
you will look for
classifying
dehydration according
to WHO criteria?
Write down
management plan for
rehydration of this
child.

2. A 10 months old child weighing 10 kg is brought to the
emergency room with diarrhea & vomiting of one day
duration. O/E he is drowsy,eyes are sunken & skin goes back
very slowly on pinching. Pulse is 140/min & feeble.
How will you
classify his
dehydration?
How will you
manage this
child ?

4.  An 11 months old girl presents with loose motions for
7 days.She passed bloody stools in the morning & her
weight = 10 kg.O/E; She is listless & lethargic,has
sunken eyes,is unable to drink & skin pinch goes back
very slowly.
A. How would you classify the child according to
IMCI?
B. How would you manage the child in emergency?
C. Compare the composition of standard WHO ORS &
Hypo-osmolar ORS in g/L.

5. SEQ-4/UHS/S-18
A 9 months old baby, weighing 10 kg has
been admitted with H/O loose motions,
vomiting & fever for the last 2 days. O/E: he
is lethargic, not taking any thing orally &
anterior fontenelle is depressed.His pulse
rate = 140/min which is low volume.
a) Enlist four common organisms of his illness.
b) How would you manage this child?

6. SEQ-5/UHS/S-17
A mother brings her 3 yrs old boy with H/O
loose stools.He also had 2 episodes of
vomiting.
a) What questions you will ask from mother?
b) What will be your focus on examination?
c) Mention points of plan A of management.

7. SEQ-6/UHS/A-18
 An 8 months old boy presented with H/O
frequent vomiting & loose motions for 3
days.He is lethargic,has sunken eyes & his
skin is cold & ashen grey.His pulse is feeble &
capillary refill is > 3 sec.His weight is 7 kg.
a) What is the most likely diagnosis?
b) Give the treatment plan.
c) Enumerate preventive strategies of the disease.

8. SEQ-7
 You receive a call from the mother of a previously healthy 2-year-old
boy. Yesterday, he developed a temperature of 104°F (40°C), cramping
abdominal pain, emesis, and frequent watery stools. The mother
assumed he had the same gastroenteritis like his aunt and many other
children in his day care center. However, today he developed bloody
stools with mucus and seemed more irritable. While you are asking
about his current hydration status, the mother reports that he is having a
seizure. You tell her to call the ambulance and then notify the local
hospital's emergency center of his imminent arrival.
A. What is the most likely diagnosis?
B. How can you confirm this diagnosis?
C. What is the best management for this illness?
D. What is the expected course of this illness?

9. Summary
 This child was exposed in his day care center and at
home to gastrointestinal (GI) illnesses.
 He has fever, abdominal pain, and watery diarrhea
that progressed to bloody diarrhea with mucus.
 He had a new-onset seizure.

10. KEY
• Most likely diagnosis:
– Bacterial enteritis with neurologic manifestations.
• Diagnostic tools:
– Fecal leukocytes, fecal blood, and stool culture.
• Management:
– Varies with age and suspected organism;
– hydration and electrolyte correction is a priority.
– Salmonella infections are self-limited and generally are not treated except in
patients younger than 3 months or in immunocompromised individuals;
– Shigella infections, although self-limited, are generally treated to shorten the
illness and decrease organism excretion.
– Antimotility agents are not used.
• Course:
– Left untreated, most GI infections in healthy children will spontaneously
resolve.
– Extraintestinal infections are more likely in immunocompromised individuals.

11. MCQ-1
 A three years old girl is suffering from loose
motions & vomiting for the last 7 days,common
type of electrolyte/acid base disturbances in this
child are as follows except
A. Hyponatremia
B. Hypokalaemia
C. Acidosis
D. Alkalosis.
E. Hypernatremia

13. MCQ-2
A 4-years old boy is C/O loose motions &
vomiting for 5 days.He was fed salty water
instead of ORS & is dehydrated.Investigations
show serum Na= 155meq/L.Following are
specific signs of dehydration in this child except:
A. Bounding pulse
B. Doughy skin
C. Irritability
D. Hypotension.

15. MCQ-3
A 1-year old girl weighing 5 Kg & length= 70
cm is having loose motions & vomiting for 10
days.The clinical sign denoting dehydration
in this child is:
A. Dryness of oral mucosa
B. Loss of skin elasticity.
C. Sunken eyes
D. Thready pulse.
E. Depressed anterior fontenella

17. MCQ-4
The indication of antibiotics in acute
gastrointestinal infection is:
A. Schigella infection.
B. Sick malnourished
C. Cholera
D. All of the above
E. None of the above

19. MCQ-5
The alternative to ORS formula is
A. Sugar & salt solution
B. Rice kanji
C. Both
D. None

21. MCQ-6/UHS
Sodium concentration in low- osmolar ORS is:
A. 20 mmol/L
B. 65 mmol/L
C. 80 mmol/L
D. 75 mmol/L
E. 90 mmol/L

22. MCQ-7/UHS
Five years old boy referred for recurrent
diarrhea. For prevention of diarrhea you will
suggest him:
A. Rota virus vaccine
B. Lactose free formula
C. Zinc supplementation
D. High protein diet
E. ORS

23. MCQ-8
 Acute diarrhoea in children:
A. Often requires careful attention to fluid intake to
prevent dehydration
B. Is usually bacterial & therefore requires antibiotic
treatment
C. Is very rarely infectious to other children
D. Is a cause of failure to thrive
E. Typically presents with blood in the stools.

24. KEY-8
A
 Diarrhoea can lead to dehydration unless fluid intake is not
maintained. In a child presenting with dehydration you will need to
carefully rehydrate them.
 Most gastroenteritis is viral and highly infectious.
 Weight loss in acute diarrhoea is usually due to dehydration (loss of
body water) and only chronic or recurrent diarrhoea causes failure
to thrive in the longer term.

25. MCQ-9
In a 12.5 kg child with 10% dehydration.
A. The maintenance fluid requirements over 24 hours are 12.5
kg (12500 mLs) × 10% = 1.25 L
B. The maintenance fluid requirement is 1.125 L
C. The total fluids required over 24 hours = fluid deficit + 10%
of maintenance
D. The fluid deficit is 1.125 L
E. The maintenance fluid volume should be given via NG tube
but the deficit fluid volume should be given as intravenous
saline (0.9%) over 4 hours.

26. KEY-9
B
 Maintenance = 100 ml × 10 kg plus 50 ml × 2.5 kg =
1125 mLs.
 The child will of course also need the deficit (10% ×
12.5 kg = 1.25 L) replacing over 24 hours, and the
safest way to do this is orally, via an NGT

27. MCQ-10
 A 6 year old child weighing 15 kg has had diarrhoea for 1 week.
O/E; he has a dry mouth, heart rate = 135/min , BP = 40/20 mm
Hg & a sunken fontanelle. He is irritable but conscious. Which of
the following is true?
A. The signs are this child is chronically malnourished
B. This child has more than 10% dehydration and requires
urgent fluid replacement over 4–6 hours
C. This child requires a rapid infusion of 150–300 mLs 0.9%
saline intravenously
D. This child is about 5–10% dehydrated and needs urgent
oral rehydration fluid via mouth or nasogastric tube
E. This child is 5% dehydrated but is probably in shock due to
sepsis or some other cause.

28. KEY-10
C
 This child is significantly dehydrated (>10%) and also has a
very low blood pressure and tachycardia suggestive of shock.
This could be confirmed by checking the central capillary refill
time.
 The shock should be corrected with a bolus of intravenous
fluids before rehydration therapy is administered carefully
over the following 24 hours.

29. MCQ-11
 A family reunion picnic went awry when the majority of attendees
developed emesis and watery diarrhea with streaks of blood. Unaffected
attendees did not eat the potato salad. A few ill family members are
mildly febrile. They come as a group to your clinic, seeking medications.
Which of the following is the most appropriate management for their
condition?
A. Antimotility medication
B. Hydration and careful follow-up
C. Intramuscular ceftriaxone
D. Oral amoxicillin
E. Oral metronidazole

30. KEY-11
B
 This family probably has Salmonella food poisoning.
 Antibiotics are not indicated for this healthy family, and
antimotility agents may prolong the illness.
 Frequent handwashing should be emphasized.

31. MCQ-12
 You are asked to see a 1-month-old infant to provide a second opinion.
During a brief, self-limited, and untreated diarrheal episode the previous
week, his primary physician ordered a stool assay for Clostridium difficile
toxin; the result is positive. The infant now is completely asymptomatic,
active, smiling, and well hydrated. His physician said treatment was not
necessary, but the mother wants treatment. Which of the following is
the most appropriate response?
A. Clostridium difficile commonly colonizes the intestine of infants;
treatment without symptoms is not warranted.
B. The infant should take a 7-day course of oral metronidazole.
C. The infant should take a 10-day course of oral vancomycin.
D. The infant should be admitted to the hospital for intravenous
metronidazole
E. A repeat study to look for the C difficile organism is warranted.

32. KEY-12
A
 Clostridium difficile colonizes approximately half of normal healthy
infants in the first 12 months.
 In this infant without a history of antibiotic treatment or current
symptoms, treatment is unnecessary.
 C difficile colitis rarely occurs without a history of recent antibiotic
use.

33. A 6 yrs old girl presented with anorexia, easy fatigability & bone pains
for 6 mons. She was operated for spina bifida in neonatal period. O/E,
weight = 12 kg, height = 90cm(<5th centile),BP= 130/90 mm Hg.She is
markedly pale & has genu valgum.S.calcium= 7.8 mg/dl,
S. phosphate=6 mg/dl, alkaline phosphatese = 800 IU & ABG’s reveal
metabolic acidosis.
What is the
most likely
diagnosis?
Write down
investigations
to confirm the
diagnosis?
Enlist steps of
management?