INFORMATION FOR CANDIDATE:

You are the GP in a rural setting. A young father,

Ray Jones brings in his 6 months old son,
Steven, with diarrhoea which started yesterday.
He has been passing watery stools for 3-4 times
a day since yesterday.
YOUR TASK IS TO:
1. Take a further history
2. Examine the child (ask findings from the
examiner)
3. Manage the patient.

HOPC:
You are the GP in a rural setting. A young father, Ray Jones brings in his 6 months old
son, Steven, with diarrhoea which started yesterday. He has been passing watery stools for
3-4 times a day since yesterday. There was no blood or mucous. His older brother, James,
had diarrhea 2 weeks ago which settled spontaneously after 3-4 days.
Steven is feeding well, alert, not drowsy, no vomiting, no fever or rash.
BINDS questions:
B: normal birth on term
I: has not had immunizations because mum and dad believed it was not necessary.
N: breastfed, no problems
D: normal development so far, 50th percentile re growth and weight, no visual or hearing
problems
S: one sibling as mentioned above
PHx. + FHx.: unremarkable
SHx: lives with mum, dad and older brother, no problems at home (25 minutes from
hospital!)
EXAMINATION: quite well looking 6 months old baby boy with normal vital signs,
normal skin turgor, capillary refill and moist mucous membranes, anterior fontanel not
sunken in.
ENT examination and the rest of the physical examination are normal.
INVESTIGATIONS:
stool for microscopy, culture and sensitivity
DIAGNOSIS: DIARRHOEA due to acute infectious gastroenteritis (most likely
viral) in an unimmunized child
Diarrhoea is defined as a measured stool volume > 10 ml/kg/day with the consistency
(loose or watery) and frequency (> 3 / 24 hours) important factors!
Clinical signs are vomiting, fever and watery diarrhoea often with poor feeding leading to
dehydration and electrolyte imbalance!
Blood and/or mucous in the stool with frequent small volume bowel actions and
abdominal pains suggest bacterial gastroenteritis!
In Australia, diarrhea is most commonly caused by rota virus!
We stratify diarrhoea into:
1. MILD: <5% body weight loss, decreased peripheral perfusion, thirsty, alert,
restless
2. MODERATE: 6-9% body weight loss and symptoms as above and in addition
rapid pulse, sunken eyes and fontanelle with dry mucous membranes, capillary
refill delayed (1-2 seconds), sometrimes deep acidotic breathing
3. SEVERE: >9% body weight loss and all of the above signs, plus drowy, limp, cold
sweaty, cyanotic limbs, rapid and feeble pulse, capillary refill delayed > 2 seconds
DIFFERENTIAL DIAGNOSES:
SYSTEMIC INFECTIONS: UTI, pneumonia, other sepsis
SURGICAL CONDITIONS: appendicitis, intussusception, Hisrschsprung disease
Antibiotic diarrhoea, haemolytic uraemic syndrome
MANAGEMENT:

Depending on the degree of diarrhea and dehydration an appropriate plan for re-hydration
(oral rehydration solutions / ORS, nasogastric or i.v.) and nutritional support needs to be
implemented!
1. MILD: oral or N/G rehydration with frequent, small amounts of fluid like
gastrolyte, hydralyte or repalyte (glucose-facilitated sodium transport in the small
intestine!); breast feeding can be continued, introduce solids after 24 hours
2. MODERATE: oral or N/G rehydration as above, sometimes iv! Consider hospital
admission depending on child, parents and distance from hospital.
3. SEVERE: urgent, rapid iv rehydration with normal saline!
NO ANTIDIARRHOEAL MEDICATION!!!
USUALLY NO ANTIBIOTICS, except in the very young (<3 months) or immunecompromised if salmonella or campylobacter involved, but always in shigella!!!
The amount of fluid requirements is calculated as the loss via dehydration plus the
maintenance (24 hours), e.g. in a 3 -6 /12 baby with 10 kg and 7.5 % dehydration:
7.5% of 10 kg
= 750 ml
maintenance of 100 ml/kg
= 1000 ml
TOTAL:
= 1750 ml
In our case the baby could be sent home, because he was not dehydrated and the parents
live only 25 min from the hospital.
Red flags: if child is drowsy or not feeding well, diarrhoea not getting better , please
bring him to the hospital immediately. Arrage social worker if mum needs support.
Take care of hand hygiene. Wash hands before food and after changing nappies.
Another consultation for discussion of need for immunization should be arranged!!!