CP 4

CP 4 DINIE HAZIRAH BT HASAN NUR FARAH DINA BT MOHD SAIDAINUL BASYIRAH BT JUSTI @ SAINIISMAH AQILA BT KAMARUDDINAMALINA BT AZMANWAN ENIS FARAHAINI BT WAN MOHAMAD

HISTORY TAKINGDINIE HAZIRAH BINTI HASAN012012100161

PATIENT IDENTIFICATIONNAME : MUHAMAD RIDWANDATE OF BIRTH : 9th JUNE 2012AGE : 2 years 7 monthsSEX : MaleRACE : MALAYRELIGION : ISLAMADDRESS : RAWANG

RN : SB00428014BED NO. : 25WARD : 8CDATE OF ADMISSION : 14th JANUARY 2015DATE OF CLERKING : 14th JANAUARY 2015INFORMANT : Mother MDM. BAZILAH (reliable sorce)

CHIEF COMPLAINTFever, cough and runny nose for 4 days.Diarrhea and vomiting for 3 days.

HISTORY OF PRESENTING ILLNESSAccording to the mother, Ridwan was apparently well 4 days prior to admission. On day 1 of illness, her child developed fever. Mother noticed that child was warm on touch and fever was intermittently occurred. Fever was not associated with chills and rigor and did not subsides with sweating.On the same day of illness, the child started to cough. Cough was productive but patient unable to expectorate the sputum. It was non-whooping cough or barking cough in nature. There were post-tussive vomiting for few times and the vomitus contained clear mucus together with food particles.

Shortly after, Ridwan started to develop runny nose. The discharge was clear in colour and there was no blood stained noticed. He did not sneeze, however discharge was persistently flow. Runny nose was not influenced by any changes in temperature or any external factors.On the evening, patient was brought to a private clinic in Rawang by his parent. Temperature recorded at GP was 38c. Syrup PCM and cough syrup were given by the doctor.

On 2nd day of illness, patient experienced diarrhea and vomiting. Mother started to noticed that her child was passing loose stool in the morning. Stool was dark brown in colour and in a small quantity. He passed stool for about 2 times on that day and patient was crying after passing stool.On the same day, Ridwan was unable to eat or drink. Every time he ate, he will start vomiting and the vomitus contained food particles. Mother tried to give him ORS but he refused to drink it.On day 3 and 4, diarrhea was getting worse as patient start to pass watery stool together with food particles. It was in large quantity which is full his diapers and he passed stool for about 2-3 times. Patient was still unable to tolerate any food.

Mother also noticed that his urine output was decreased and patient look lethargy and pale. When her son cried, she noticed that it was tearless. Mother denied of giving outside food to her child or had travel for past few months before her child sick. She also mentioned that her son had no contact with other person with same disease and there was no other family members that had the same problems. Mother also claimed that the last episode of fever which is just before his admission to the ward was associated with chills and rigor and gradually subsides after admission. On admission, IV fluid was given and FBC was done. His weight was measured and he had lose for about 2kg of his weight.

Systemic review :Generally, patient had experienced chills and rigor once during illness and he look lethargy.CVS no bluish discoloration of lips, tongue, nails, skin and no sweating.Respiratory no breathing difficulty, no rapid breathing or nose bleed.CNS no drowsiness, headache, or fits. Patient alert and conscious.ENT no pus or ear discharge, present of nasal discharge which is clear in colour.

GIT vomiting, passes loose stool, no fullness of tummy, lose 2kg of his weight.Genitourinary urine output decrease but no foul smelling blood noticed in urine. Skin no swelling or eczema on skin.

HISTORY OF PAST ILLNESSPatient had never been hospitalized before and no surgical intervention was done.

BIRTH HISTORYAntenatal:Mother was regularly attended her antenatal check up at Klinik Kesihatan nearby her house. She had been received one dose of anti-tetanus toxoid injection and took all the medication given such as folic acid and iron tablets during her pregnancy. Serology test was done and the result were negative for VDRL, HIV and HbsAg. Her blood group is A-positive. She had never experienced any fever with rashes, trauma, antepartum hemorrhage or radiation exposure through out the pregnancy. She denied of having gestational diabetes mellitus, pregnancy induced hypertension, anemia, urinary tract infection or other chronic illness such as asthma and epilepsy during pregnancy. She had never consumed alcohol nor drug abuse.

Natal:Ridwan was a full term baby delivered by spontaneous vaginal delivery at 40 weeks period of gestation in HSB. No instrument or anesthesia given to assist delivery.Postnatal:Baby cried immediately after birth and mother breastfed him within 1 hour after birth. Baby weighted 2.5 kg and had no complication after birth. He passed urine and meconium on the same day of birth.

FEEDING & DIETARY HISTORYPrelacteal feeding was not given.The child was given exclusive breastfeeding up to 3 months and after that mother started to mix with formula milk named Lactogen. He is feeding on demand and the preparation of milk is 1 scoop for 1 ounce of water.Complementary feeding was given at 6 months.Currently he consumed adult diet and also drinks Milo for 4-5 times a day, about 7-8 ounce.

IMMUNIZATION HISTORYIt is completed as per national Expanded Programme on Immunization (EPI) schedule.VACCINEAGE (months)01235612BCGHepatitis BDTaPIPVHibMMR

GROWTH & DEVELOPMENTAL HISTORYGross motor:Able to walk and runAble to go upstairs and downstairsVisual and fine motor:ScribbleSpeech and language:Able to say few words with meaning; eg: mama, kakak, nasi, nak loAble to understands orders from parents

Emotional and social behavior:Able to put on shoes and dress by himselfAble to interact with stranger and play with children around his age

MEDICATION & ALLERGYNo known history of drug, food and other allergies.

FAMILY HISTORY29yo29yo6y2y7m9m8y

This is non-consanguineous marriage. His father is 29 years old and mother also 29 years old. Both his parents are healthy, but mother had history of asthma during childhood.He had 4 total of siblings, and he is the third one. All the other siblings are healthy. His maternal grandfather and all maternal siblings had asthma. Paternal grandmother had heart disease and hypertension.No other history of chronic illnesses such as epilepsy, diabetes mellitus and malignancy. Mother had no history of abortion, intrauterine death and neonatal death.

SOCIO-ECONOMIC HISTORYPatients father work as a labor while her mother work at a factory. Their family monthly income is about RM2000 and is enough to maintain their current standard of living.Patient is living with their parents in an apartment in Rawang. The area have good ventilation and sanitation. The neighbourhood is situated in a clean environment but near dengue area. Parents are non-smoker.

PHYSICAL EXAMINATIONNUR FARAH DINA BINTI MOHD SAID

012012100139

GENERAL EXAMINATIONThe patient is lying comfortably in supine position.He was conscious but slightly fatigue and showed no signs of respiratory distress.The patient is small built,moderately nourish and looked moderately dehydrated.There present of ID tag on his left hand and branulla line on his right hand.There present of running iv drip.No nasal prongs or face mask was seen on the child.ORS also seen on the table nearby.

Vital signsBlood pressure: 90/54 (Normal for age)Pulse rate: 96 bpm(Normal rate, regular rhythm, good volume & good character)Respiratory rate: 35 breath/min (Normal for age)Temperature: (Afebrile)SPO2 : 98 %(Normal)

Anthropometry Weight: 10 kg(Weight lies below 3rd percentile which means child is underweight)Length: 93 cm(Length is normal lies between 50th and 75th percentile)HC: 45cm(Head circumference lies below 3rd percentile)

Hydration StatusSunken eyesTired and consciousAble to drinks properlyNormal skin turgor

HEAD TO TOE EXAMINATIONHead-Head shape appeared symmetrical.-Anterior fontanel was closed-There is no dysmorphic features on the faces.-No sunken anterior fontenelles are observed.

Eyes- Slightly sunken eyes present - Otherwise no pallor,no icterus,no periorbital edema, no discharge,no hemorrhage.

Ears- Ears appear normal. No pus or ear discharge

Nose- No nasal flaring, no nasal discharge, no nasal polyp and no deformities

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Mouth-Lips are not cracked and not dry. Tongue are not coated and mucosal area are moist. No central cyanosis is seen.

Hand-Hand are warm,moist and pink in colour-Capillary refill time are less than 2 seconds.-Prominent palmar crease,no palmar erythema,no koilonychia,no clubbing of finger.-No peripheral cyanosis are seen.

Skin-Skin are pink in colour and not mottled.-Normal skin turgor.

Legs-No pitting edema was seen on the legs.

ABDOMEN EXAMINATIONInspection-Abdomen is not distended,no scar,no strech mark.-No rash, no visible pulsation,no visible dilated vein.

Palpation-The abdomen is soft and non tender-No any abdominal mass was felt.-No hepatosplenomegaly and kidney is not ballotable.

Auscultation-Normal bowel sound present

Percussion-Tympanic on all quadrant-There is no shifting dullness-There is no fluid thrill

RESPIRATORY SYSTEMInspectionThe chest is bilaterally symmetrical and moves symmetrically with inspirations.No visible dilated vein and pulsation are seen.No surgical scar or hyperpigmentation of skin.Normal chest shape, no pectus carinatum,pectum excavantum and barrel shape.Respiratory rate are and not tachypnoeaNo subscostal,intercostal,supracostal recession are seen.No accesory muscle are used during respiration.

Palpation-Trachea was centrally located- The chest expansion was normal and equally on both side.

Auscultation-Air entry is good,equally bilatterally.-Good,equal vesicular breath sound was heard with no additional sound heard

CARDIOVASCULAR SYSTEMInspectionThe precordium showed no deformityNo precordial pulsation was observedNo surgical scars was seen

PalpationApex beat is felt at 4th intercostal space at mid clavicular line.

AuscultationS1 and S2 heart sound can be heard with no additional sound and murmur.

SUMMARYMuhammad Ridzwan, a 2 year and 7 month old Malay boy admitted into HSB on 14th January 2014 came with fever,cough,running nose for 4 days,diarrhea and vomitting for 3 days prior to admission.According to the mother the child experienced tearless cry and had reduced in urine output.

On examination,the child appeared malnourished as weight for age is plotted on growth chart is below than 3rd percentile.The child also had loses 2 kg of his weight from 12 kg to 10 kg for the past two months and the eyes are sunken.

AINUL BASYIRAH BINTI JUSTI@SAINI012012100154DIAGNOSIS

Muhammad Ridzwan, a 2 year and 7 month old Malay boy admitted into HSB on 14th January 2014 came with fever,cough,running nose for 4 days, and diarrhea and vomitting for 3 days prior to admission.

On examination, child was found to have weight loss and sign of dehydration which was sunken eyes.

My provisional diagnosis would be GASTROENTERITIS.

PROVISIONAL DIAGNOSIS:ACUTE GASTROENTERITIS

ACUTE GASTROENTERITISPOINTS SUPPORTPOINTS AGAINSTLoose watery stoolLow grade fever VomitingNone

DIFFERENTIAL DIAGNOSIS:

- BACTERIAL DIARRHEA- URINARY TRACT INFECTION (UTI)

BACTERIAL DIARRHEAPOINTS SUPPORTPOINTS AGAINSTFeverDiarrheaVomiting Low grade feverNo blood in stool

URINARY TRACT INFECTION (UTI)POINTS SUPPORTPOINTS AGAINSTFeverVomiting Diarrhea No increase in micturition frequencyNo crying while passing urineNo hematuria

INVESTIGATIONAMALINA BT AZMAN012012100140

FBC

- to check if it was infection : WCC, Plt to access severity of dehydration : hematocrit

RESULTSUNITNORMAL RANGEWCC9.5x 10^9/L5.3-11.5Hb11.7g/dL10.5-12.7HCT36.7g/dL31.7-37.7Plt438x 10^9204-405

RENAL FUNCTION TEST

to detect electrolyte imbalance if present rise in urea and creatinine may be due to dehydration

RESULTSUNITNORMAL RANGEUrea1.6mmol/L1.8-6.0Sodium136mmol/L135-148Potassium3.10mmol/L3.5-5.8Chloride102.0mmol/L102-112Creatinine43.9umol17.7-61.9

Stool samples

microscopy (include ova, cysts and parasites)

culture and sensitivity. to detect specific organism

Ascaris lumbricoidsNo ova or cyst seenTrichuris trichiuraNo ova or cyst seenEnterobius vermicularisNo ova or cyst seenAncylostoma duodenaleNo ova or cyst seenEntamoeba histolyticaNo ova or cyst seen

Rotavirus detection

as the most common virus affecting children

RotavirusNEGATIVE

Other test..

- not significant to the illness to access severity of the illness

RESULTSpH7.36pCO244pO226.6BE0HCO323.1

VBG check for pH value assess oxygen concentration

LIVER FUNCTION TESTRESULTS UNITNORMAL RANGETotal Protein69.0g/L54.0-75.0Globulin32g/L23-35Albumin/Globulin Ratio1.15-1.2-1.5Total Bilirubin7.1umol/L3.0-22.0Alanine Transaminase17U/L8-20Albumin37g/L35-50Alkaline Phosphate150U/L40-160

MANAGEMENTISMAH AQILA KAMARUDIN012012100136

First, assess the state of perfusion of the childSign of shock:-tachycardia-weak peripheral pulse-delayed CRT-cold peripheries-depressed mental state with or without hypotension

Assessment

-mild dehydration 10% dehydratedTreatment: Plan C, give fluid for severe dehydrationChilds general conditionLethargic or unconsciousLook for sunken eyeSunken eyesFluid intakeNot able to drinkSkin turgorSkin goes back very slowly

PLAN A: TREAT DIARRHEA AT HOMECounsel the mother on 3 rules for home treatment:Give extra fluid:Breastfeed frequentlyFor exclusive breastfeed, give ORS or cooled boiled water in addition for breast milk.Not exclusive breastfeed, give one or more of the following: ORS, food-based fluid or cooled boiled waterGive frequent small sips from a cup or spoonIf child vomit, wait for 10 minute before continue more slowlyContinue give fluid until diarrhea stop

2. Continue feedingBreast feed infant should continue breastfeed on demandFormula fed should continue their usual formula immediately on rehydrationContinue give semi-solid or solid food to receive their usual food during illnessAvoid foods high in simple sugar as osmotic load may worsen the diarrhea3. When to return (clinic/hospital)When the child:Not able to drink or breastfed poorlyBecomes sickerDevelop feverBlood in the stool

PLAN B: TREAT SOME DEHYDRATION WITH ORSGive recommended amount of ORS over 4 hourly

Calc: childs weight(kg) x 75Reassess the child condition after 4 hours

Age Upto 4months4-12 months12monhts- 2years2-5yearWeight20kg=20ml/kg)

Reassess the hydration status frequently (1-2 hourly) and adjust infusion as necessary.Start give more maintenance fluid as soon as the child can drink and administered it in small volumesFeed should be administered in addition to rehydration fluid, infant continue breastfeedOnce the child able to feed and not vomit start plan A or B and IV drip can reduced gradually and taken off.

DISCUSSION ON ACUTE GASTROENTERITIS

BY: WAN ENIS FARAHAINI WAN MOHAMAD012012100135

DEFINITION-AGE : sudden onset of passing loose watery stool >3 times per day and resolve within 7-10 days.

GastroenteritisIn developing countriesIn developed countries

Mostly cause by bacterial from contaminated drinking water & foodresult in death from dehydration of thousands of children worldwide every yeartreatment by ORSMostly cause by viralalso can be caused by Campylobacter, Shigella, Salmonellainfants are particularly susceptible to dehydrationORS is the most effective, but IV fluids require for shock, ongoing vomitting / clinical deterioration

ETIOLOGYVIRALBACTERIALPARASITES1. Rotavirus (common, 60% in children 3 in the previous 24 hourIf they have been unable to tolerate to feeding / extra fluidsIf they have malnutrition

Why infants are at high risk of dehydation?they have greater surface area to weight ratio than older children (lead to greater insensible water loss)they have higher basal fluid requirementsdue to immature renal tubular reabsorptionunable to obtain fluids for themselves when thirst

How to assess the degree of dehydration?

1. No clinically detectable dehydration (10%)

*Signs of shock:tachycardiaweak peripheral pulsedelayed CFT >2s cold peripheriesdepressed mental status with / without hypotension

Clinical assessment of dehydrationMILDMODERATESEVEREChilds conditionWell, alertRestless / irritableLethargic / unconciousSunken eyesNo Yes Yes Orally fluidDrinks normallyDrinks eagerly, thirstyNot able to drink / drinks poorlySkin turgorNormal, go back immediatelyGoes back slowlyGoes back very slowly (>2s)Percentage of dehydration10% dehydratedTreatment PLAN A-give fluid & food to treat diarrhoea at homePLAN B-give fluid &food for some dehydrationPLAN A-give fluid for severe dehydration

DehydrationISONATRAEMICHYPONATRAEMICHYPERNATRAEMIClosses of Na & water are proportionalplasma Na remains within the normal rangegreater net loss of Na> water (thus fall in plasma sodium)happen when children with diarrhoea drink large quantities of water / other hypotonic solutionscause shiftness of water from extra to intracellularincrease intracellular volume in brain, leads convulsionmarked extracellular depletions lead to a greater degree of shock per unit of water lossthis dehydration commonly in poor nourished infants in developing countriesgreater net loss of water>sodiumincrease plasma Na concentrationresult from high insensible water losses (high fever, dry hot environment) / profuse, low Na diarrhoea.cause shiftness of water from intracellular to extracellular

Indication IV therapyunconcious childpersist (>3x / hour), severe vomitdrink poorlycontinue rapid stool loss (15-20ml/kg/hr)abdominal distension with paralytic ileus (cause by anti diarrhael: loperamide)glucose malabsorption (seen by increase stool output, & large amount of glucose in stool)

Indication for admission to hospitalmoderate to severe dehydrationneed IV therapyconcern for other possible illness / uncertain of diagnosispatient factors : young age, worsening symptomscaregiver not able to provide adequate care at home

Others problem associated with diarrhae1. Fever-may be due to another infection-always search for the source of infection if there is fever, especially if it persists after the child is rehydrated

2. SeizuresConsider:-febrile convulsion-hypoglycemic-hyponatraemia

Other problems associated with diarrhae3. Lactose intolerance-usually in formula fed babies