CP 4

DINIE HAZIRAH BT HASAN

NUR FARAH DINA BT MOHD SAID
AINUL BASYIRAH BT JUSTI @ SAINI
ISMAH AQILA BT KAMARUDDIN
AMALINA BT AZMAN
WAN ENIS FARAHAINI BT WAN
MOHAMAD

HISTORY TAKING
DINIE HAZIRAH BINTI HASAN
012012100161

PATIENT IDENTIFICATION

NAME : MUHAMAD RIDWAN

DATE OF BIRTH : 9th JUNE 2012
AGE : 2 years 7 months
SEX : Male
RACE : MALAY
RELIGION : ISLAM
ADDRESS : RAWANG

RN : SB00428014
BED NO. : 25
WARD : 8C
DATE OF ADMISSION : 14th JANUARY
2015
DATE OF CLERKING : 14th JANAUARY
2015
INFORMANT : Mother MDM.
BAZILAH (reliable sorce)

CHIEF COMPLAINT
1. Fever, cough and runny nose for 4
days.
2. Diarrhea and vomiting for 3 days.

HISTORY OF PRESENTING
ILLNESS
According 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-

 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

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

vi. GIT vomiting, passes loose stool, no

fullness of tummy, lose 2kg of his weight.
vii.Genitourinary urine output decrease
but no foul smelling blood noticed in
urine.
viii.Skin no swelling or eczema on skin.

HISTORY OF PAST ILLNESS

Patient had never been hospitalized
before and no surgical intervention
was done.

BIRTH HISTORY
Antenatal:
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 Apositive. 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

HISTORY
Prelacteal 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 HISTORY
It is completed as per national
Expanded Programme on
Immunization (EPI)
schedule.
VACCINE
AGE (months)
0

BCG
Hepatitis B
DTaP
IPV
Hib
MMR

12

GROWTH & DEVELOPMENTAL

HISTORY
i. Gross motor:
. Able to walk and run
. Able to go upstairs and downstairs
ii. Visual and fine motor:
. Scribble
iii. Speech and language:
. Able to say few words with meaning; eg:
mama, kakak, nasi, nak lo
. Able to understands orders from parents

iv. Emotional and social behavior:

. Able to put on shoes and dress by himself
. Able to interact with stranger and play
with children around his age

MEDICATION & ALLERGY

No known history of drug, food and
other allergies.

FAMILY HISTORY
29yo

8y

6y

29y
o

2y7m

9m

 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 HISTORY
Patients 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 EXAMINATION
NUR FARAH DINA BINTI MOHD SAID
012012100139

GENERAL EXAMINATION
The 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 signs
Blood 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 Status
Sunken eyes
Tired and conscious
Able to drinks properly
Normal skin turgor

HEAD TO TOE EXAMINATION

Head
-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

 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 EXAMINATION
Inspection
-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

RESPIRATORY SYSTEM
Inspection
The 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 tachypnoea
No subscostal,intercostal,supracostal

 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 SYSTEM
Inspection
The precordium showed no deformity
No precordial pulsation was observed
No surgical scars was seen
Palpation
Apex beat is felt at 4th intercostal space at mid clavicular
line.
Auscultation
S1 and S2 heart sound can be heard with no additional
sound and murmur.

SUMMARY
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,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.

DIAGNOSIS
AINUL BASYIRAH
BINTI JUSTI@SAINI
012012100154

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 GASTROENTERITIS
POINTS
SUPPORT

Loose watery
stool
Low grade fever
Vomiting

POINTS AGAINST

None

DIFFERENTIAL DIAGNOSIS:
- BACTERIAL DIARRHEA
- URINARY TRACT INFECTION
(UTI)

BACTERIAL DIARRHEA
POINTS
SUPPORT

POINTS
AGAINST

Fever
Diarrhea
Vomiting

Low grade
fever
No blood in
stool

URINARY TRACT INFECTION (UTI)

POINTS
SUPPORT

Fever
Vomiting
Diarrhea

POINTS AGAINST

No increase in
micturition
frequency
No crying while
passing urine
No hematuria

INVESTIGATION
AMALINA BT AZMAN
012012100140

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

UNIT

NORMAL
RANGE

WCC

9.5

x 10^9/L

5.3-11.5

Hb

11.7

g/dL

10.5-12.7

HCT

36.7

g/dL

31.7-37.7

Plt

438

x 10^9

204-405

RENAL FUNCTION TEST

o detect electrolyte imbalance if present

ise in urea and creatinine may be due to dehydratio
RESULTS

UNIT

NORMAL
RANGE

Urea

1.6

mmol/L

1.8-6.0

Sodium

136

mmol/L

135-148

Potassium

3.10

mmol/L

3.5-5.8

Chloride

102.0

mmol/L

102-112

Creatinine

43.9

umol

17.7-61.9

Stool samples
- microscopy (include ova, cysts and parasites)
Ascaris lumbricoids

No ova or cyst seen

Trichuris trichiura

No ova or cyst seen

Enterobius
vermicularis

No ova or cyst seen

Ancylostoma
duodenale

No ova or cyst seen

Entamoeba histolytica No ova or cyst seen

-culture and sensitivity.

to detect specific organism

- Rotavirus detection
as the most common virus affecting children
Rotavirus

NEGATIVE

Other test..
- not significant to the illness
- to access severity of the illness

 VBG
- check for pH value
- assess oxygen concentration
RESULTS
pH

7.36

pCO2

44

pO2

26.6

BE

HCO3

23.1

 LIVER FUNCTION TEST

RESULTS

UNIT

NORMAL
RANGE

Total Protein

69.0

g/L

54.0-75.0

Globulin

32

g/L

23-35

Albumin/Globu 1.15
lin Ratio

1.2-1.5

Total Bilirubin

7.1

umol/L

3.0-22.0

Alanine
Transaminase

17

U/L

8-20

Albumin

37

g/L

35-50

Alkaline
Phosphate

150

U/L

40-160

MANAGEMENT
ISMAH AQILA KAMARUDIN
012012100136

 First, assess the state of perfusion of

the child
Sign of shock:
-tachycardia
-weak peripheral pulse
-delayed CRT
-cold peripheries
-depressed mental state with or
without hypotension

 Assessment
Childs
Well and alert
general
condition
Look for sunken No sunken eyes
eye
Fluid intake
Drinks normally
-mild
<5%
dehydrated
Skin dehydration
turgor
Skin
goes
back
immediately
Treatment: Plan
A, give fluid and

food to treat diarrhea at home

 Assessment
Childs
Restless or irritable
general
condition
Look for sunken Sunken eyes
eye
Fluid intake
Drinks eagerly
Skin
2turgor
above sign,
moderate
Skin
goes back slowly

dehydration 5-10% dehydrated

Treatment: Plan B, give fluid and
food for some dehydration

 Assessment
Childs
Lethargic or
general
unconscious
condition
Look for sunken Sunken eyes
eye
Fluid intake
Not able to drink
Skin
2 turgor
above sign,Skin
severe
goes dehydration
back very
>10% dehydrated
slowly

Treatment: Plan C, give fluid for

severe dehydration

PLAN A: TREAT DIARRHEA AT HOME

Counsel the mother on 3 rules for home treatment:
1. Give extra fluid:
-. Breastfeed frequently
-. For 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
water
-. Give frequent small sips from a cup or spoon
-. If child vomit, wait for 10 minute before continue
more slowly
-. Continue give fluid until diarrhea stop

2. Continue feeding
Breast feed infant should continue breastfeed on
demand
Formula fed should continue their usual formula
immediately on rehydration
Continue give semi-solid or solid food to receive
their usual food during illness
Avoid foods high in simple sugar as osmotic load
may worsen the diarrhea
3. When to return (clinic/hospital)
When the child:
- Not able to drink or breastfed poorly
- Becomes sicker
- Develop fever
- Blood in the stool

PLAN B: TREAT SOME

DEHYDRATION WITH ORS
Give recommended amount of ORS
over 4 hourly
Age

Weight
volume

Upto
4-12
12monh
4month months tss
2years
<6kg
6-10kg
10-12kg
200400700childs
x 75
400ml weight(kg)
700ml
900ml

2-5year

12-19kg
9001400ml

Calc:
Reassess the child condition after 4
hours

PLAN C: TREAT SEVERE

DEHYDRATION
Start IV or IO fluid immediately
If patient can drink, give ORS orally while
setting the drip
- Initial fluids for resuscitation of shock: 20ml/kg
of NaCl 0.9% or Hartman solution as rapid
bolus
- Repeated if necessary until patient is out of
shock or if fluid over load suspected.
- Fluid for rehydration( % of dehydration x
body weight in grams) + maintenance fluid
(1st 10kg=100ml/kg, next 10kg= 50ml/kg,
>20kg=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 volumes
Feed should be administered in
addition to rehydration fluid, infant
continue breastfeed
Once 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 MOHAMAD
012012100135

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

Gastroenteritis
In developing countries
Mostly cause by bacterial
from contaminated drinking
water & food
result in death from
dehydration of thousands of
children worldwide every year
treatment by ORS

In developed countries
Mostly cause by viral
also can be caused by
Campylobacter, Shigella,
Salmonella
infants are particularly
susceptible to dehydration
ORS is the most effective,
but IV fluids require for
shock, ongoing vomitting /
clinical deterioration

ETIOLOGY
VIRAL

BACTERIAL

PARASITES

1. Rotavirus
(common, 60% in
children <2years,
particularly during
winter & early
spring)
2. Others :
adenovirus,
norovirus,
calicivirus,
coronavirus,
astovirus (may cause
outbreaks)

*less common in developed countries.

*suggested by the presence of blood in the
stools.
1. Campylobacter jejuni
commonest in bacterial infection
associated with severe abdominal pain
2. Shigella & some Salmonella
produce dysenteric type of infection, blood
and pus in the stool
tenesmus (spurious feeling of the need to
evacuate bowels with little / no stool passed )
pain
3. Cholera & enterotoxigrnic E.coli
associated with profuse, rapidly dehydrating
diarrhoea.

1. Entamoeba
histolytica
2. Giardia
lamblia
3. Spore-forming
intestinal
protozoa
(eg:
Cryptosporidian
parvum, Isopora
belli,
Cyclospora
cayetanensis)

Children at increased risk of dehydration

Infants <6months or born with low birthweight
If they have passed >6 diarrhoeal stool in the
previous 24 hour
If they have vomited >3 in the previous 24 hour
If they have been unable to tolerate to feeding /
extra fluids
If 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 requirements
due to immature renal tubular reabsorption
unable to obtain fluids for themselves when
thirst

How to assess the degree of dehydration?

1. No clinically detectable dehydration (<5%)
2. Clinically dehydration (5-10%)
3. Shock (>10%)
*Signs of shock:
tachycardia
weak peripheral pulse
delayed CFT >2s
cold peripheries
depressed mental status with / without hypotension

Clinical assessment of dehydration

MILD

MODERATE

SEVERE

Childs
condition

Well, alert

Restless /
irritable

Lethargic /
unconcious

Sunken eyes

No

Yes

Yes

Orally fluid

Drinks
normally

Drinks
eagerly, thirsty

Not able to
drink / drinks
poorly

Skin turgor

Normal, go
back
immediately

Goes back
slowly

Goes back
very slowly
(>2s)

Percentage of
dehydration

<5%
dehydrated

5-10%
dehydrated

>10%
dehydrated

Treatment

PLAN A
-give fluid &
food to treat
diarrhoea at
home

PLAN B
-give fluid
&food for some
dehydration

PLAN A
-give fluid for
severe
dehydration

Dehydration
ISONATRAEMIC
losses of Na & water
are proportional
plasma Na remains
within the normal range

HYPONATRAEMIC

greater net loss of Na> water

(thus fall in plasma sodium)
happen when children with
diarrhoea drink large quantities of
water / other hypotonic solutions
cause shiftness of water from
extra to intracellular
increase intracellular volume in
brain, leads convulsion
marked extracellular depletions
lead to a greater degree of shock
per unit of water loss
this dehydration commonly in
poor nourished infants in
developing countries

HYPERNATRAEMIC
greater net loss of
water>sodium
increase plasma Na
concentration
result from high insensible
water losses (high fever, dry
hot environment) / profuse,
low Na diarrhoea.
cause shiftness of water
from intracellular to
extracellular

Indication IV therapy
unconcious child
persist (>3x / hour), severe vomit
drink poorly
continue 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 hospital

moderate to severe dehydration
need IV therapy
concern for other possible illness / uncertain of
diagnosis
patient factors : young age, worsening
symptoms
caregiver not able to provide adequate care at
home

Others problem associated with diarrhae

1. 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. Seizures
Consider:
-febrile convulsion
-hypoglycemic
-hyponatraemia

Other problems associated with diarrhae

3. Lactose intolerance
-usually in formula fed babies <6months with infectious
diarrhoea
-clinical features:
persistent loose/watery stool
abdominal distension
increased flatus
-treatment
if diarrhoea persist & watery over 7-10 days & evidence
of lactose intolerance, give lactose free formula
normal formula be reintroduced after 2-3 weeks

Investigations
1. Full Blood Count
2. Stool analysis: WBC, pH
3. Stool culture is required:
if the child appears septic
if there is blood or mucus in the stools
the child is immunocompromised
indicated following recent foreign travel
if diarrhoea has not improved by day 7
if the diagnosis is uncertain

Investigations
4. Plasma electrolytes and urea level : to check
the degree of dehydration & when IV fluid is
required
5. Rotavirus Antigen test
6. Blood culture: should be taken if antibiotics
are started.

Management of dehydration
PLAN A
PLAN B
1. Give extra
1. Give the
fluids (ORS)
recommended
2. Continue
amount of ORS
feeding
over 4 hour
3. When to return
period
-not able to drink/ 2. Reassess the
breastfeed
child after 4 hour
-becomes sicker
& classify the
-develop fever
dehydration
-has blood in stool 3. Begin feeding the
child
Monitor the I/O chart

PLAN C
1.

2.
3.

4.

Initial fluids for

resuscitation of
shock: 20ml/kg of
Hartmann
solution (rapid IV
bolus)
Calculate the fluid
needed over the
next 24 hours
Reassess the
hydration status
frequently (1-2
hourly) & adjust
infusion if
nessecary
Begin oral
feeding if the
child able to

Management of AGE
-Pharmacological agents:
1.Antimicrobials
used of antibiotics only in children with bloody diarrhoea,
propable shigellosis and suspected cholera with severe
dehydration
2. Antidiarrhoeal medications
locally diosmectite (Smecta) has been shown to be safe &
effective in reducing stool output & duration of diarrhoea.
Help by restoring integrity of damaged intestinal epithelium
& capable to bind to selected bacterial pathogens and rotavirus.

Management of AGE
2. Antidiarrhoeal medications
other anti diarrhoeal agents like koalin (silicates),
loperamide (anti motility) & diphenoxylate (anti motility)
- NOT RECOMMENDED.
3. Zinc supplements
taken during episode of diarrhoea reduce the duration
& severity of episode & lower the incidence of diarrhoea
in the following 2-3 months.
WHO recommends to take this as soon as possible after
diarhoea has started.

Management of AGE
3. Zinc supplements
taken for 10-14 days with dose
up to 6 months : 10mg/day
age 6 months and above : 20mg/day

THANK YOU :)