Demographic details Name Patients initial Date of birth R/N Age Gender Ethnic group Date of admission Date

of discharge Ward of admission Informant Address 1)Presenting complaint(s) Adam Danial a 4 months old Malay boy was admitted to Hospital Sungai Buloh presented with more than 10 episodes of diarrhea with history of 3 days of fever and runny nose prior to admission. 2)History of presenting complaint(s) Mother claimed that AD had more than 10 episodes of diarrhea at home.It had started on Tuesday evening.The stool was watery,yellowish colour and offensive odour but there was not blood stained or mucus.Mother also claimed that the pampers was flooding everytime AD had pass stool.The diarrhea still not resolve when mother gave him oral rehydration salt which got from clinic.Upon of that,AD looked lethargy and his tongue and lip was dry but he can tolerate orally. He also had history of 3 days of fever and runny nose prior to admission but it was resolve by taking syrup paracetamol which got from clinic.There was no history of fit before. There was no complaint of episode of vomiting associated with diarrhea. 3)Systemic review System General Complaint(s) Pale,drowsy,poor hydration and nutritional status(body weight had reduced from 5.8kg to 5.45kg,dry tongue and lip),no cyanosis ,no rashes,not in respiratory distress No cough,no wheezing,no stridor,no shortness of breath No cyanosis Adam Danial Abdullah AD 9/6/2011 SB00372453 4 months Male Malay 20/10/2011 (2pm) 21/10/2011 8C Mother Subang Bestari,Sg Buloh

Respiratory system Cardiovascular system

Gastrointestinal system Central nervous system Endocrine Skin Genitourinary symptoms Musculoskeletal system Ear ,nose & throat 4)Past Medical and Surgical History

Diarrhea,no vomiting,no hematemesis,no dysentry No seizure,no abnormal movement No cold or hot intolerance No rashes,no jaundice,no pallor No oliguria ,no hematuria Normal limb movement Runny nose,no stridor

No significant past medical history and surgical history 5)Drug History No significant history 6)Allergies No known food and drug allergies 7)Birth History During antenatal period , mother did not developed any complication. He was delivered by emergency lower segment caesarean section at term due to twin presentation at Hospital Kuala Lumpur with 2.1kg of body weight. He was placed in the incubator for one week after birth due to low birth weight but not his twin sister. He had developed jaundice at 3 days of life whilst he was in incubator but his sister had not developed jaundice. 8)Feeding History He was exclusively breasfed up to 1 week and continue with formula milk ,Snow,until now because of mother has underlying Hepatitis B. 9)Immunisation History up to his age Immunization Age (Months) Birth 1 BCG / Hep B / DTP OPV HiB MMR

2 / / / /

3 / / / /

10)Developmental Milestones Correspond to the chronological age 11)Family History He is the second child out of 2 siblings.He had twin sister ,4 months old, and now live healthy and well. His father ,48 years old,does not underlying any longterm illnesses but his mother, 39 years old ,is underlying Hepatitis B and currently on medication. All siblings of maternal side except 5th aunt underlying Hepatitis B and also grandmom who already died due to same disease . There is no consanguinity marriage. 12)Social and environmental history His father works as contractor and a smoker while his mother works as bank officer and not a smoker.Their education level until SPM and STPM each.Both of them not taking any illicit drug or consume alcohol.Their family income is about RM8000 monthly.They live in 5th floor of apartment with elevator accommodation which consist of 4 members at Subang Bestari,Sg Buloh and have good basic amenities.Mother also claimed that the surrounding was dirty and smelly due to unmanage rubbish and that place is dengue prone area but there have fogging for every week until now. 13)History of contact Mother had send his sister and him to babysitter but the other childs and his twin sister were not developed same symptom like him 14)Effect of illness on the patient and the family Mother had to take leave to take care of him while twin sister was take care by father.

Physical examination A)General examination i. General condition AD, a 4 months old malay boy was lying comfortably in supine position and supported by one pillow.The patient look lethargy and pallor.He had cannula inserted on his dorsum of right hand while his left hand was swollen up to axilla may be due to side effect of insertion of cannula before.He was not in any kind of respiratory distress Impression :the patient seemed lethargy and pallor.He was not in respiratory distress. ii. Vital signs: Pulse :116beats per minute with regular rythm and normal volume Respiratory rate :38 breaths per minute Temperature : 360C Blood pressure : 103/50 mmHg Impression : He was not tachypnoeic or tachycardic and afebrile. iii. Anthropometry Weight : 5.45 kg (previously 5.8 kg) Height :63 cm Head circumference :40.5 cm Impression : based on centile chart,his weight is on 5th centile,height is on 50th centile and head circumference is on 10th centile. Examination for hydration status He was mildly dehydrated by the evidence of sunken anterior fontanelle ,less skin turgidity,cold extremeties,dry tongue and lips and look lethargy. Impression :He was dehydrated

iv.

v.

Examination of face ,head&neck,limbs Head,face and neck No dysmorphic feature on all parts of the body Head : anterior fontanelle had mildly sunken Eyes :no jaundice or pallor Mouth : no central cyanosis,uncoated tongue or no angular stomatitis. Neck : not examined

Upper limb Hands :pink,cold peripheries,CRT <2 seconds,no peripheral cyanosis.There were swelling of left hand up to axilla resulting from insertion of cannula previously. Lower limb Cold peripheries,no swelling of both legs or no bruise Impression : findings were normal except the cold peripheries of upper and lower limbs and swelling of left hand up to axilla. vi. Examination of back There were no scar or bruises noted.no abnormality of spine detected Impression :back condition was normal Vii. Examination of lymph nodes Not examined B) Systemic examination: Respiratory system Inspection : The chest shape was normal and no chest wall deformity such as pectus carinatum or pectus excavatum. The chest moved symmetrically with respiration. There were no scar, superficial dilated vein, skin discolouration and visible pulsation. Palpation : The chest expansion was symmetrical bilaterally. Percussion : Lung resonance was present on the right and left chest. Auscultation : The air entry was equal on both sides. There was normal vesicular breathing sound with inspiratory phase much longer than expiratory. There were no added sounds Impression : no abnormalities detected

Abdominal examination Inspection : The abdomen was slightly distended and move symmetrically with respiration. The umbilicus was centrally located and inverted. There were no scar, no skin pigmentation and no superficial dilated vein noted.no scrotal swelling or ambiguous genitalia,mild perianal excoriation

Palpation : The abdomen was soft and there was no area of tenderness. There were presences of vibrations felt when abdomen was palpated. Even so there were no palpable mass noted. The liver and spleen were not palpable. The kidneys were not ballotable and no hernia. Percussion : No shifting dullness and fluid thrill noted. Auscultation : Bowel sounds tremendously increased. Impression : there were accumulation of gas and also increase in peristalsis movement evident by the presence of vibrations upon palpitation and also increase in bowel sounds. Cardiovascular system Inspection : The chest wall moved symmetrically with respiration. The chest shape was normal with no chest wall deformity. There were no surgical scar, superficial dilated vein, skin discolouration, visible pulsation and pericardial bulge. Palpation : On palpation, all peripheral pulses were present. The apex beat was palpated at 5th left intercostal space at midclavicular line. No parasternal heave and thrill at left sternal edge, pulmonary area and aortic area. Percussion : not done Auscultation : First heart sound and second heart sound was heard. There were no added murmurs Apex beat was auscultated on fifth left intercostals space at midclavicular line. Impression : Normal heart sound S1 and S2 was heard indicates presence of normal dual rhythm heart sounds with no added murmurs. There were no other abnormal findings noted. Musculoskeletal system Have signs of inflammation of left hand due to IV line ,no muscle wasting or hypertrophy .No bony deformities and no signs of inflammation of other parts Impression : The left hand was inflamed

Central nervous system A. Higher function : i.Mental status : He was conscious ii.Speech: cannot communicate yet iii.Sleep: well iv.Orientation: not develop yet v.Intelligence: not develop yet vi.Memory:not develop yet

B.Cranial nerve : CN I (olfactory nerve) not examined CN ll (optic nerve) not examined CN lll (oculomotor nerve) intact CN lV (trochlear nerve) - intact CN V(trigeminal nerve)- not examined CN Vl (abducens nerve)- intact CN Vll (facial nerve)- not examined CN Vlll (vestibulocochlear nerve) not examined CN lX (glossopharyngeal nerve) not examined CN X (vagus nerve) not examined CN Xl (accessory nerve) not examined CN Xll (hypoglossal nerve) not examined C)Motor function i) Muscle:bulk - normal tone - normal strength - normal

ii)Reflexes:

Ankle Knee Plantar iii) Coordination

Right Not examined Not examined Not examined

Left Not examined Not examined Not examined

a)Finger nose test - not examined b)Heel shin test not examined iv) Gait cannot walk yet

D)Sensory function i)Pain not examined ii)Touch not examined iii)Temperature not examined iv)Vibration sense- not examined v)Position sense not examined vi)Recognition of size,shape,weight and form of objects not examined E)Signs of meningeal irritation i)Neck stiffness not examined ii)Kernigs sign not examined iii)Brudzinskis sign- not examined

Clinical summary AD, a 4 months old malay boy was sent to Hospital sungai buloh on Thursday with suspected to have mild dehydration due to complained of more than10 times episodes of diarrhea without vomiting.

Provisional diagnosis Acute gastroenteritis Point to support : very young age, more than 10 times episodes of diarrhea(watery,yellowish colour,offensive odour).

Differential diagnosis 1) Urinary tract infection Point to support history of fever for three days,diarrhea, kept in wet nappies Point to against no vomiting 2) Food poisoning Point to support excessive diarrhea Point to against- never taken other food except formula milk

Investigations Full blood count Parameter WBC RBC Hb Hct MCH MCV MCHC Platelet Renal profile Parameter Urea Na K Cl Creatinine Result 2.7 143 3 124 32.2 Normal range 3.2- 7.4 136- 145 3.5 5.1 111 130 64 - 111 Interpretation Abnormal Normal Abnormal Normal Abnormal Result 8.6x103 /uL 5.42 x10e6/uL 15.1 g/dL 40.2% 27.9pg/cell 85.2 fl 32.7g/dL 340x10e3/uL Normal range 4.1-10.9 4.0-5.2 11.1-14.1 36-45 25-31 70-74 30-35 110-450 Interpretation Normal Abnormal Abnormal Normal Normal Abnormal Normal Normal

C - reactive protein : 0.6 mg/dL Stool reducing sugar positive Stool culture and sensitivity no ova and cyst seen

Final diagnosis Acute gastroenteritis with severe dehydrated Principles of management Maintain airway Establish breathing Reinstate circulation o Bolus and rehydration correction should be given stat to reinstate the circulation back to normal preventing cellular hypoxia and also acute renal failure.

Daily progress Upon admission ,AD looked lethargy but he became looked more alert after bolus was given.vital signs were taken and there were normal.his hydration status and perfusion had improved.mother claimed that he can tolerating milk well,no vomiting,no fever but the diarrhea still persist but in small amount of watery stool and anterior fontanelle minimally sunken. On second day,intravenous drip was continue.AD looked more active that he can moving all 4 limbs,comfortable,no diarrhea,no vomiting,no fever,can tolerate orally,good hydration and perfusion and anterior fontanelle had raised to normal.

Discussions In this case,it seemed that AD had manisfested a typical presentation of acute gastroenteritis which was more than 10 times episodes of diarrhea which not resolve with oral rehydration salt at the beginning. Acute gastroenteritis is a leading cause of childhood morbidity and mortality and is also important cause of malnutrition.many diarrheal deaths are caused by dehydration from fluid and electrolytes loss.mild and moderate dehydration cac be safely and effectively treated with ORS solution but severe dehydration needs intravenous fluid therapy.

Firstly,assess the state of perfusion of the child.if the child is in shock,go straight to treatment plan C.this is WHO chart to assess the degree of dehydration and to choose proper treatment. Look at childs general condition Look for sunken eyes Offer the child fluid Pinch skin of abdomen Classify Well,alert No sunken eyes Drinks normally Skin goes back immediately No dehydration(,5%) Give fluid and food to treat diarrhea at home Treatment plan A Restless or irritable Sunken eyes Drinks eagerly,thirsty Skin goes back slowly Some dehydration(510%) Give fluid and food for some dehydration Treatment plan B Lethargic or unconscious Sunken eyes Not able to drink or drinks poorly Skin goes back very slowly(.2sec) Severe dehydration(10%0 Give fluid for severe dehydration Treatment plan C

treat

Determining the amount of ORS to give in the first 4 hours 12 months 2 2-5 years years Weight <6kg 6 - <10kg 10 - <12kg 12-19kg In mL 200-400 400-700 700-900 900-1400 If we do not know the childs weight,use the childs age only.the approximate amount of ORS required(in ml) can be calculated by multiplying the childs weight (in kg) x 75. Age Up to 4 months 4-12 months If the patient wants more ORS than shown,give more.

Indications for intravenous therapy -severe dehydration -unconscious child -continuing rapid stool loss -frequent,severe vomiting,drinling poorly -abdominal distension with paralytic ileus -glucose malabsorption

Intravenous therapy 1.fluid deficit Fluid deficit (mls)= % dehydration x body weight in grams 2. maintainence fluid therapy -type of fluid solution: 1/5 normal saline 5% dextrose solution or 1/2 normal saline 5% dextrose with or without added KCl in the drip Volume of fluid required: -less than 6 months age : 150ml/kg/day -6 months to 1 year age : 120ml/kg/day - more than 1 year age : 1st 10kg=100ml/kg 10 20 kg=1000ml for first 10 kg + 50ml/kg for next 10 subsequent kg >20kg=1500ml for first 20 kg+20ml/kg for any subsequent kg

3. Treating metabolic acidosis -metabolic acidosis usually self corrects with rehydration -correction only required if pH<7.1 -formula for calculation of sodium bicarbonate correction: IV 8.4% NaHCO3 (mEq or ml) =1/3 x base deficit x weight;usually only half this volume (1/2 correction) is given -review with a repeat blood gas 4. Electrolyte requirement and replacement formula - normal daily requirement of K+=2-3 mmol/kg/dayxbody weight (kg) -normal daily requirement of Na+=2-3 mmol/kg/day x body weight (kg) -Sodium deficit (mmol) =(140- patients serum Na level x 0.6 x weight(kg) Indications for admission to Hospital -need for intravenous therapy -concern for other possible illness or uncertainty of diagnosis -Patients factor,eg :young age,unusual irritability/drowsiness,worsening symptom -caregivers not able to provide adequate care at home -social or logistical concerns that may prevent return evaluation if necessary

INVESTIGATIONS Test

Justification General Test 1. Assessing the total WBC differential predominance of lymphocytes and granulocytes (deduce the eatiological agent) 2. Acessing the haematocrit assess the severity of fluid loss (dehydration) Hct will increase in dehydration

Full Blood Count

RP

To see the renal function especially when she had profuse diarrhea and vomiting she already has tremendous loss of fluid. Beware of acute renal failure secondary to dehydration. To see the renal function and efficacy as we might aspect renal failure in patient who has severe dehydration To see the access the liver function to exclude any liver cause Detect inflammation

UFEME

LFT

C-reactive protein

Electrolytes and ions Detect any level of circulating electrolytes and ions Specific Diagnostic Test Lumbar Puncture Stool C & S Blood C & S Urine C & S To Rule out encephalitis To detect causative agent To try to isolate and determine causative agent To rule out upper urinary tract infection/ find causative agent Radiological/imaging CT scan To look for any brain damage that may explain the cause of seizure

Discharge summary AD a 4 months old malay boy presented with more than 10 times of diarrhea episodes with history of 3 days of fever and runny nose prior to admission have been diagnosed to have AGE with severe dehydration and metabolic acidosis. He was treated as AGE with severe dehydration and metabolic acidosis Patient had improved a lot and diarrhea had resolved by hydration status had been stabilised,can tolerate orally well and no fever documented. Upon discharging,AD looked active with good hydration status and anterior fontanelle become normal and normal vital signs.