Morning Report

Tuesday, 12th December of 2017

2nd Team
Identity
 Name: Mrs. H
 Age : 60 Years Old
 Address: Naasir Street No.12, Cawang
 Educational Background : High School
 Status : Married
 Nation : Indonesian/Javanese
 Religion : Moslem
Chief Complain : Fatigue since 3 hours ago.
Chief Complain : Fatigue since 3 hours ago.
Physical Examination
 LOC: E4 M6 V5
 BP: 120/80 mmHg
 HR: 110x/min
 RR: 23x/min
 T: 37,7°C
General Examination
 Head: Normocephaly
 Eye: conjunctiva anemic -/-
 sclera icteric -/-
 ENT: normal
 Mouth: normal
 Neck: No lymph node enlargement
 Thorax:
 Ins: Symmetrical respiratory movements
 Pal: Symmetrical vocal fremitus
 Per: Sonor sounds all over lung platform
 Aus: lungs sounds vesicular
Rhonchi -/-, Wheezing -/-, Heart sound I & II regular, Murmur -
/-, Gallop -/-
Continued…
 Abdominal:
 Ins: Appeared flat
 Aus: Intestinal sounds (+), 7x/min
 Per: Timpanic, percussion pain (-), acites (-)
 Pal: Pressure pain (-), release pain (-), defense muscular (-)
Therapy
 IVFD:
 III RL / 24 hours
 MM/
 Pumpitor inj 1x1 IV
 Ondansentron 4mg 2x1 IV
 Ceftriaxone 2gr 1x1 IV
 New Diatabs 2 tabs every diarrhea
Planning
 Pro-hospitalized
References
Acute Gastroenteritis
 Acute Abdomen

Intraluminal Extraluminal Gastrointestin Paralytic Blunt Miscellaneous

Obstruction Obstruction al Ileus Trauma
Disease

Foreign Body Hernia Appendicitis Sepsis Accident Lead poisoning

Bezoar Intussusceptio Crohn disease Pneumonia Battered child Sickle cell
Fecalith n Ulcerative Pyelonephritis syndrome disease
Gallstone Volvulus colitis Peritonitis Familial
Parasites Duplication Vasculitis Pancreatitis Mediterranean
Stenosis Peptic ulcer fever
Cystic fibrosis Cholecystitis
Tumor disease Porphyria
Tumor Renal stones
Mesenteric cyst Meckel’s DKA
Fecaloma Gallstones
SMA syndrome AGE Addisonian
PID crisis
Pyloric stenosis Lymphadenitis Testicular
torsion
Ovarian Torsion
Approach
 History
 Symptoms
 Nausea, emesis, retching
 Abdominal pain
 Bowel movements
 Timing
 Age
 Onset
 Relation to feeds
 Focus of infection, other affected individuals
Approach
 Physical examination
 Temperature, heart rate, blood pressure, pain
 Abdominal examination
 Auscultation before palpation
 Palpation
 Masses
 Tenderness
 Auscultation for bowel sounds
Approach
 Objectives
 Assess the degree of dehydration
 Prevent spread of the enteropathogen
 Selectively determine etiology and provide specific therapy
Dehydration
 Mild (3-5%)
 Normal or increased pulse
 Decreased urine output
 Thirsty
 Normal physical exam
Dehydration
 Moderate (7-10%)
 Tachycardia
 Little/no urine output
 Irritable/lethargic
 Sunken eyes/fontanelle
 Decreased tears
 Dry mucous membranes
 Skin- tenting, delayed cap refill, cool, pale
Dehydration
 Severe (10-15%)
 Rapid, weak pulse
 Decreased blood pressure
 No urine output
 Very sunken eyes/fontanelle
 No tears
 Parched mucous membranes
 Skin- tenting, delayed cap refill, cold, mottled
Dehydration
 Treatment
 Calculate deficits
 Water: % dehydration x weight
 Sodium: water deficit x 80 mEq/L
 Potassium: water deficit x 30 mEq/L
 Treat mild-moderate dehydration with oral rehydration
solutions
 May treat severe dehydration with intravenous fluids
 Hyponatremic v. isotonic v. hypernatremic
Etiology
 Enteropathogens
 Non-inflammatory vs. inflammatory diarrhea
 Non-inflammatory
 Enterotoxin production
 Destruction of villi
 Adherence to GI tract
 Inflammatory
 Intestinal invasion
 Cytotoxins
Etiology
 Chronic diarrhea
 Giardia lamblia
 Cryptosporidium parvum
 Escherichia coli: enteroaggregative, enteropathogenic
 Immunocompromised host
 Non-infectious causes: anatomic, malabsorption,
endocrinopathies, neoplasia
Etiology
 Bacterial
 Inflammatory diarrhea
 Aeromonas
 Campylobacter jejuni
 Clostridium dificile
 E. coli: enteroinvasive, O157:H7
 Plesiomonas shigelloides
 Salmonella
 Shigella
 Vibrio parahaemolyticus
 Yersinia enterocolitica
Etiology
 Bacterial
 Non-inflammatory
 E. coli: enteropathogenic, enterotoxigenic
 Vibrio cholerae
 Viral
 Rotavirus
 Enteric adenovirus
 Astroviruus
 Calcivirus
 Norwalk
 CMV
 HSV
Etiology
 Parasites
 Giardia lamblida
 Entamoeba histolytica
 Strongyloides stercoralis
 Balantidium coli
 Cryptosporidium parvum
 Cyclospora cayetanensis
 Isospora belli
Diagnosis
 History
 Stool examination
 Mucus
 Blood
 Leukocytes
 Stool culture
Diagnosis
 Examination for ova and parasites
 Recent travel to an endemic area
 Stool cultures negative for other enteropathogens
 Diarrhea persists for more than 1 week
 Part of an outbreak
 Immunocompromised
 May require examination of more than one specimen
Antimicrobial therapy
 Aeromonas
 TMP/SMZ
 Dysentery-like illness, prolonged diarrhea
 Campylobacter
 Erythromycin, azithromycin
 Clostridium dificile
 Metronidazole, vancomycin
 E. coli
 TMP/SMZ
Antimicrobial therapy
 Salmonella
 Cefotaxime, ceftriaxone, ampicillin, TMP/SMZ
 Infants < 3 months
 Typhoid fever
 Bacteremia
 Dissemination with localized suppuration
 Shigella
 Ampicillin, ciprofloxacin, ofloxacin, ceftriaxone
 Vibrio cholerae
 Doxycycline, tetracycline
Therapy
 Antidiarrheal medication
 Alter intestinal motility
 Alter adsorption
 Alter intestinal flora
 Alter fluid/electrolyte secretion
 Antidiarrheal medication generally not recommended
 Minimal benefit
 Potential for side effects
Prevention
 Contact precautions
 Education
 Mode of acquisition
 Methods to decrease transmission
 Exclusion from day care until diarrhea subsides
 Surveillance
 Salmonella typhi vaccine