Pediatrics Department

Case Presentation

Irah Franz D. Flores

Block I Group D
Date and Time: December 12, 2017, 2pm
Source: Mother and Grandmother
Reliability: 90%
General Data

B. J.
3 year old
Male
Roman Catholic
Address: Urgello, Cebu
Date of Birth: December 01, 2014
Place of Birth: Cebu City
Admitted at CDUH on December 11, 2017
Chief complaint

Bloody Diarrhea
History of Present Illness
1 Day PTA
2 Days PTA
10 episodes of Diarrhea
• Foul smelling
Baby wasn’t able to eat or
• yellowish
drink, was given with tap
• mucoid
water.
• bloody
• ~ 1 cup per episode
Brought to Sacred Heart
Fever Tmax 38.5C
Center ER (+) tonsilitis
Given Co-amoxiclav 4ml
Management: No meds given
3x a day by the ER
Physician
Associated Symptom:
Weakness
No Associated Symptoms:
Anorexia
•fever
Irritability
• cough
(-)changes in urination, sleeping
• chills
pattern
 2 hours PTA

2 episodes of Diarrhea
• ~1 cups per episode
• same character

Management: ORS
(1000 ml)

Associated Symptom:
Anorexia
Weakness
(-)fever
(-)changes in urination,
sleeping pattern
Pre-natal History

• Mother: 17y/o ; G1P0(0-0-0-0)

• Prenatal check-up
• 12 weeks AOG
• OBGYNE
• Subsequent visits: irregular
Laboratory tests
• CBC, urinalysis, FBS and ultrasound

No illnesses during pregnancy

Non-alcoholic, non-smoker
Natal History
• Delivered Term via NSVD
• OB Resident at Cebu City Medical Center
• 1st in rank
• Good cry upon delivery
• No cyanosis
• Birth weight: 3.5 kg
• No perinatal complications
Post Natal History
Feeding
• Exclusively Breastfed for 1 year and 3 months
• Mixed fed -6 months onwards
o Semi-solid foods
o Lugaw
o Cerelac
o Mashed Vegetables
o Present Diet:
o cerelac
o fresh fruits
o random foods (any family members hand to the patient sometimes without regards with
sanitation)
Growth and Developmental Milestone
1 month
 Social smile
5 months
 Good head control, unsupported
7 months
 Transfers objects from hand to hand
 Sits without support
9 months
 Says “mama” and “papa”
 Stands with support
11 months
 walks
• Immunizations at a Local Health Center
– BCG (at birth)
– HepB (at birth)
– Pentavalent Vaccine (6, 10,17 weeks)
– OPV (6,10,17 weeks)
– Measles ( 9 months)
– MMR (12 months)
– Rotavirus (6, 10, 14 weeks)
– Pneumoccocal vaccine (6, 10 ,14 weeks)
Past Medical history

• No previous hospitalizations
• No food or drug allergies
Family/ Medical History

• Both parents - healthy

• Heredofamilial Diseases:
– Hypertension - paternal side
– Asthma -maternal side
Personal and Social History

• Father- 21 y/o; Customer Service Representative at Vivo

Communications
• Mother- 21 y/o; housewife
• Bungalow house
– Electricity
– Near an open canal
– Own toilet
– Mineral Water for drinking
General: recent weight change(13 kg), any clothes that fit more
tightly or loosely than before. Weakness, fatigue, fever.
Skin, Hair, Nails: rashes, lumps, sore, itching, dryness, color
change, changes in hair/nails.
Head: Headache, head injury, dizziness, lightheadedness.
Eyes: vision, pain, redness, excessive tearing, sunken eyeballs
Ears: hearing, earaches, discharge.
Nose: nasal stuffiness, discharge
Throat: bleeding gums, dry mouth, frequent sore throats,
hoarseness.
Neck: lumps, swollen glands, pain, stiffness.
Breast: pain or discomfort, nipple discharge.
Respiratory: cough, sputum, hemoptysis, dyspnea, wheezing,
asthma, bronchitis, pneumonia, tuberculosis.
Circulatory: rheumatic fever, chest pain or discomfort, dyspnea,
orthopnea, edema
Gastrointestinal: trouble swallowing, appetite, nausea, bowel
movements, hemorrhoids, constipation, diarrhea, abdominal
pain, food intolerance, excessive belching, jaundice
Urinary: polyuria, nocturia, burning or pain on urination,
hematuria, decreased urine output, urinary infections.
Genital: discharge, exposure to HIV infection.
Musculoskeletal: swelling, redness, pain, tenderness, weakness,
history of trauma.
Hematopoietic: anemia, easy bruising or bleeding, past
transfusions
Metabolic/Endocrine: heat or cold intolerance, excessive
sweating, excessive thirst or hunger, polyuria
Psychiatric: nervousness, sudden mood changes
Neurologic: fainting, blackouts, seizures, weakness
Physical Examination
• GENERAL SURVEY
• Examined patient awake, conscious, weak, afebrile, not in
respiratory distress

• VITAL SIGNS
• HR – 121 bpm; apical pulse
• RR - 28 cpm
• BP – 80/60 mmHg
• Temp – 36oC/ Right axilla

• ANTHROPOMETRIC MEASUREMENTS
• Height: 105 cm z-score= 2 HC: 53.5 cm
• Weight: 13kg z-score= -1 CC: 55 cm
AC: 54cm
SKIN:
Inspection:
Fair complexion, (-) jaundice, (-) cyanosis, (+) rashes

Palpation:
Cool, dry
poor turgor
HEAD:
Inspection:
• Symmetric, normocephalic, atraumatic
• Scalp hair well-distributed
• No dilated scalp veins, no scaling, no rashes
Palpation:
• No lumps noted, no masses , no tenderness
Percussion:
• No facial grimacing upon tapping of cheek
(-) Chvostek's sign
EYES:
Inspection:
• Anicteric sclera, (-) conjunctival redness, (-) lens
opacities, pupils isocoric
• Sunken eyeballs
• Complete lid closure,
• Full extraocular movements, OU, no nystagmus
• (+) ROR
Palpation:
• No tenderness around orbital rim
• Good rebound pressure
EARS :
Inspection:
• Both pinnae in line with lateral canthus
• (-) gross deformities, (-) lesions,
• Blinks eyes in response to sudden sharp sound
or voice
• intact typmanic membrane with minimal moist
cerumen, (-) inflammation, (-) foreign body, no
discharges

Palpation:
• No tenderness, no masses
NOSE and PARANASAL SINUSES:
Inspection:
• Symmetric, septum at midline, pink nasal mucosa
• No secretions, no inflammation, no alar flaring
Palpation:
• No tenderness over maxillary and frontal sinuses

ORAL CAVITY/THROAT:
Inspection:
• Dry lips
• pink oral and buccal mucosa,
• dentition: all upper and lower central and lateral incisors fully erupted
upper left first molar partially erupted
• Tongue midline, uvula midline, no exudates
Palpation: Intact hard palate,
NECK:
Inspection: symmetric, no webbing, supple
Palpation:
• trachea midline, thyroid cartilage midline
• No palpable lymph nodes, no masses

BREAST, AXILLA, NODES:

Inspection:
• Symmetric, small nipple and areola, no lesions
Palpation:
• Smooth, nipples without discharge,
• no enlarged lymph nodes
CHEST and LUNGS:
Inspection:
• Symmetric chest walls, no gross deformity
• No retractions, no use of accessory muscles
• RR=28 cpm, regular rhythm, unlabored breathing
• No audible breath sounds
Palpation:
• Symmetric chest expansion, equal tactile fremitus
Percussion: resonant throughout
Auscultation: clear breath sounds, (-) wheezes and
crackles
CARDIOVASCULAR:
Inspection:
• No cyanosis, external jugular vein not distended
• PMI at the level of 5th intercostal space
Palpation:
• Carotid upstrokes brisk, no thrills
Auscultation:
• HR=121bpm, regular, bounding
• Distinct S1 and S2, (-) S3 or S4, (-) murmur
ABDOMEN :

Inspection:
• Protuberant, symmetric, slightly visible blood
vessels, inverted umbilicus with no signs of
inflammation, no hernia, no dilated veins, no
rashes, not distended
Palpation:
• Liver and spleen edge non palpable; aortic
pulsations felt
• Non-sensitive, non tender
Percussion: tympanitic throughout
Auscultation: hyperactive bowel sounds
GUT:
Inspection:
• Grossly male, foreskin completely covers glans
penis, penis straight, scrotum with rugae
• Tanner Stage 1
• No swelling, no rashes
Palpation:
• No tenderness, both testes inside scrotal sacs
• No masses
EXTREMITIES:
Inspection
• No gross deformities, no signs of inflammation
• No cyanosis, no ulceration, no hip dislocation
• Full range of motion in all limbs
Palpation:
• No tenderness
• Palpable, tapping peripheral pulses
SENSORIUM: awake, not crying
CRANIAL NERVES:
I- not done
II – regards face
III, IV, VI – blinks in response to light, equally rounded pupils,
reactive to light,
(+) consensual and direct pupillary light reflex OU
extraocular movments full in all 6 directions
V – responds to touch on cheek, tickled by cotton
VII – no facial asymmetry
VIII – responds to voices, tracks sound,
IX, X – able to swallow
XI – symmetrical shoulders, able to shrug
XII – tongue midline
MOTOR:
• good muscle tone, no tremors, strong grasp
SENSORY: reacts to soft touch on face symmetrically

REFLEXES:
• 2+ throughout
CEREBELLAR: active spontaneous movement
MENINGEAL SIGNS:
(-) Brudzinski's sign, (-) Kernig's sign
Summary of Important Findings
• 2 days of acute bloody diarrhea
• Given tap water to drink
• weakness
• anorexia
• random foods (any family members hand to the patient sometimes
without regards with sanitation)
• Recent weight change
• Dry skin
• Sunken Eyeballs
• hyperactive bowel sounds
Differential Diagnosis
Rule in Rule out
Amebic Dysentery + frequent bowel movement (-) vomiting
+ age (common in 1-4 y/o) + fever
+ common in tropical countries Incubation period is within1-8 days
+ bloody stool
Cholera +fatigue, anorexia + bloody stool
+abdominal pain (-) vomiting
+diarrhea
+dehydration
Acute Viral Gastroenteritis + diarrhea (-) vomiting
(Rotavirus infection) + fever + bloody stool
+ abdominal pain

Enteric Fever (Typhoid Fever) + diarrhea (-) headache

+fever (-) hepatomegally
+anorexia
+abdominal pain
Irritable Bowel Syndrome +diarrhea (-)bloating
+abdominal pain (-) flatulence
(-) constipation
Logical Impression:

• Acute Bacterial Gastroenteritis with Mild-moderate

dehydration
Basis

• Patient has bloody mucoid stool for 2 days of more than

10 episodes
• patient had fever, anorexia and weakness, hyperactive
bowel sounds
• Breastfed for 1 year and 3 months
• Random foods given or handed to patient by any member
of the family.
• One common pathogen would be Shigella causing
dysentery.
Acute Gastroenteritis
Gastroenteritis denotes infections of the gastrointestinal tract
caused by bacterial, viral, or parasitic pathogens.
• The most common manifestations
– Diarrhea
– Vomiting
– systemic features: abdominal pain and fever
Epidemiology
• second most common cause of child death worldwide
• Younger than 5 yrs of age in developing countries
• Decline in mortality
– Rotavirus vaccine
– Improved case management of diarrhea
– Improved nutrition of infants and children
Mode of Transmission

• Fecal-oral route
• Ingestion of Contaminated water and food
• Person to person contact
Risk factors

– seasonal exposure to organisms such as rotavirus

– exposure to pathogens in settings of close contact (e.g.,
daycare centers)
– environmental contamination
– Young age
– Immunodeficiency
– Measles
– Malnutrition (nutritional deficiencies)
– lack of exclusive or predominant breastfeeding
Clinical Manifestations

• Fever
• Vomiting
• Diarrhea
• Reduced oral intake
• Abdominal pain
• Sign and symptoms of dehydration
Etiology

Bacteria Viruses Parasites

• Campylobacter jejuni • Rotavirus (most common).
• Salmonella spp. • Calicivirus • Entamoeba histolytica
• Shigella spp • Astrovirus • Giardia lamblia
• Escherichia coli
• Clostridium difficile
Shigellosis
• Shigella infections
– Causes diarrhea that is often bloody
Dysentery
Syndrome of
-bloody diarrhea with fever
-abdominal cramps
-rectal pain
-mucoid stools
Most common complication is dehydration
12 hours incubation period symptoms ensue
Shigellosis

• Epidemiology
– Most common infection in 2nd and 3rd years of life
– 70% of all episodes and 60% of all Shigella-related deaths
involve younger than 5 years old
– Breast milk contains antibodies to plasmid-coded antigens and
lipopolysaccharides
– Occurs during rainy months in tropical climates
Pathogenesis
Diagnostic Tests
– CBC
– Urinalysis
– Stool analysis
• Fecal leukocytes
• Occult blood
• Stool culture
• Stool microscopy
– Serum electrolytes, BUN, creatinine
Therapeutic
– Monitor Vital Signs q4h
– ORS
• mild-moderate dehydration – 575-1150 mL over 3-4 hours (rehydration); 120-240 mL for each diarrheal
episode (replacement of losses)

– Give adequate IV fluid therapy D5 Lactated Ringer

IV fluid replacement:
Weight: 13 kg
Holiday Segar Formula = 1000 mL + 50 mL per kg >10kg
= 1000 + 50 mL (3) kg
= 1150 mL
W/ some dehydration (>2 yrs old) = 6% x wt
=60mL x 13kg
= 780
Total = 1150mL + 780 mL
= 1930mL/day or 80 mL/hr
– Reassess q8h to guide on going fluid therapy
• Monitor signs of fluid overload
• Urine output
• Weight change
• Clinical signs of dehydration
– Give Oral Zinc 20mg/day for 10-14 days
– Vitamin A 200,000 IU
– Antibiotics TMP-SMX/ Ampicillin
– Probiotics
– Avoid giving anti-diarrheal drugs (Imodium/Lomotil) worsens illness
• Continue with other foods:

– High protein and high caloric diet

– enhance food density
– avoiding high conc of sugar and salts
– more easily digestible foods
– small frequent feedings
– for convalescence: one or two extra meals per day for same
number of sick days
Education
• Encourage good hygiene and proper food handling
• Proper hand washing with soap
• Teach how to manage potentially contaminated materials like
soiled diapers, raw vegetables