PEDIATRIC CASE

PRESENTATION
KHO, ROSCELIE L.
PDR 3 BLOCK 2
DATE: AUGUST 23, 2016 at 2:30pm

SOURCE: Maternal Grandmother and Maternal Aunt

% RELIABILITY: 93%
GENERAL DATA
K.B. 2 years old, Male

Filipino

Roman Catholic

Address: Upper Laguerta, Busay

DOB: January 14, 2014

POB: Upper Laguerta, Busay

1st admission at CDUH; August 20, 2016

CHIEF COMPLAINT

DIARRHEA
 HISTORY OF PRESENT ILLNESS
5 days PTA
Intermittent low grade fever, Tmax: 39oC

Paracetamol (Calpol) 120mg/5ml, 1 tsp (7.5ml) q4H, total of 3 doses,

temporary relief, temperature not measured after administration.

Negative of associated symptoms:

Cold
Cough
Rashes
Abdominal pain
Diarrhea
Lethargy
Vomiting
 HISTORY OF PRESENT ILLNESS
4 days PTA
Intermittent low grade fever, Tmax: 38oC; ran out of paracetamol.

Diarrhea: watery, avocado-green color, foul, non blood tinged, non

greasy, 1-2 cups per defecating episode, total 5 episodes, 3-4 hr
interval.

Medicated with Avocado & Guava Leave Decoction, cup, 2 doses; no

relief.

Associated symptoms:
Increase thirst
Poor appetite
Slight irritability
Disturbed sleep
 HISTORY OF PRESENT ILLNESS
4 hours PTA
Fever subsided.

Diarrhea: watery, avocado-green color, foul, non blood tinged, non greasy, 1-2
cups per defecating episode, total 3 episodes, 3-4 hr interval.

Vomiting: non projectile, non blood streaked, non foul smelling, cup per
episode, total of 2 episodes, minutes apart.

Associated symptoms:
Sunken eyeballs
Irritability
Increased thirst
Poor appetite
Disturbed sleep
 PRE-NATAL HISTORY
Mother, 25 years old, G2P1 (1001)

Pre-natal care:
18 weeks AOG at Upper Laguerta Health Center
Subsequent: regular at Upper Laguerta Health Center

Laboratory tests:
CBC, U/A, HBsAg, FBS, Pap Smear and UTZ: unremarkable

Vitamins: unrecalled.

Immunizations: unrecalled.

(+) alcoholic beverages, (-) smoking

 POST NATAL HISTORY
Full term 37 wks AOG

Birth rank: 2/2

NSVD

Home Delivery, midwife

Good cry

Birth weight: 2700g (estimated)

No complications noted
 FEEDING HISTORY
Exclusive breastfeeding for 2 weeks.

Formula feeding:
Enfalac: up to 6 months
Promil: up to 1 year
Progress Gold: up to 2 years
Bear brand/ Nido at present.

Semi solid food: 4-5 months old

 GROWTH AND DEVELOPMENT
2 months old
Social smile
Head control in prone position

3 months old
Lifts head and chest with arms extended
Sustained social contact

4 months old
Laughs
Reaches and grabs objects and places them in mouth
 GROWTH AND DEVELOPMENT

5 months old
Transfers object from hand to hand

6 months old
Sits with support

7 months old
Responds to tone of voice
 GROWTH AND DEVELOPMENT

12 months old
Stands alone

24 months old
Combines 2 words
Can imitate actions
Understand simple instructions
 IMMUNIZATION HISTORY

BCG and Hep B 1st dose: at birth

Received at health center:

Hepatitis B second dose: 1 month old
DPT, OPV, Hib:
1st dose: 2 months old
2nd dose: 4 months old
3rd dose: 6 months old
Hepatitis B third dose: 6 months old
MMR: 9 months old
 PAST MEDICAL HISTORY
1ST Vicente Sotto Memorial Medical Center
Mid September 2015
Age 1
Pneumonia
Discharged after 3 weeks
Without complications

Denies any form of allergy.

 FAMILY HISTORY
Mother: 26 years old, deceased, cardiac arrest from unknown medication.

Father: whereabouts unknown.

Sibling:
4 years old, male, alive and well.

Heredofamilial disease:
Diabetes mellitus
Hypertension
Stroke
 PERSONAL AND SOCIAL HISTORY
Mother deceased, 1 year ago.

Resides at maternal aunt and grandmothers house.

Maternal grandmother is legal guardian.

Purified water for drinking.

Describes living in a well knit, peaceful community.

Adequate garbage disposal.

 REVIEW OF SYSTEMS
GENERAL: Usual weight, recent weight change, any clothes that fit more tightly or loosely than before.
Weakness, fatigue, irritability, fever.

SKIN: rashes, lumps, sores, itching, dryness, color change, changes in hair or nails.

HEAD: Headache, head injury, dizziness, lightheadedness.

EYES: Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double
vision, blurred vision, spots, specks, flashing lights, glaucoma, cataracts.

Throat (or mouth and pharynx): Condition of teeth, gums, bleeding gums, dentures, if any, and how
they fit, last dental examination. Sore tongue, dry mouth, frequent sore throats, hoarseness.

NECK: Lumps, swollen glands, goiter, pain or stiffness in the neck.

BREASTS: Lumps, pain or discomfort, nipple discharge, self-examination practices.

 REVIEW OF SYSTEMS
RESPIRATORY: Cough, sputum( color, quantity), hemoptysis, dyspnea, wheezing, pleurisy, last chest x-ray. You may
wish to include asthma, bronchitis, emphysema, pneumonia and tuberculosis.

CARDIOVASCULAR: Heart trouble, high blood pressure, rheumatic fever, heart murmurs, chest pain or discomfort,
palpations, dyspnea, orthopnea, paroxysmal, nocturnal dyspnea, edema, past electrocardiographic or other heart
test results.

GASTROINTESTINAL: Trouble swallowing, heart burn, appetite, nausea, bowel movements, color and size of
stools, change in bowel habits, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea.
Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver or gallbladder trouble,
hepatitis.

URINARY: Frequency urination, polyuria, nocturia, urgency, burning or pain on urination, hematuria, urinary
infections, kidney stones, incontinence: In males, reduced caliber or force of the urinary stream, hesitancy,
dribbling.

GENITAL: MALE: Hernias, discharge from or sores on the penis, testicular pain or masses, history of sexually
transmitted diseases and their treatments. Sexual habits, interest, function, satisfaction, birth control methods,
condom use, and problems. Exposure to HIV infection.
 REVIEW OF SYSTEMS
PERIPHERAL VASCULAR: Intermittent claudication, leg cramps, varicose veins, past clots in the
veins.

MUSCULOSKELETAL: Muscle or joint pains, stiffness, arthritis, gout and backache. If present,
describe location of affected joints or muscles, presence of any swelling, redness, pain, tenderness,
stiffness, weakness, or limitation of motion or activity; include timing of symptoms (for example,
morning or evening), duration, and only history of trauma.

NEUROLOGIC: Fainting, blackouts, seizures, weakness, paralysis, numbness or loss of sensation,

tingling or pins and needles, tremors or other involuntary movements.

HEMATOLOGIC: Anemia, easy bruising or bleeding, past transfusions and/or transfusion reactions.

ENDOCRINE: Thyroid trouble, heat or cold intolerance, excessive sweating, excessive thirst or
hunger, polyuria, change in glove or shoe size.

PSYCHIATRIC: Nervousness, tension, mood, including depression, memory change, suicide

attempts, if relevant.
 PHYSICAL EXAMINATION
General Survey
Awake
Ambulatory
Non-irritable
Playful mood
Ectomorph
Slightly unkept hair
Appropriate for age
 PHYSICAL EXAMINATION

Vital Signs
BP: 90/70 mmHg, R arm
PR: 100bpm, R radial, regular, bounding
RR: 25cpm, normal depth
Temp: 37.1oC, right axilla
 PHYSICAL EXAMINATION
Anthropometric Measurements
Weight: 10kg
Height: 87.5 cm

BMI: 13.1; z score: -3.8; percentile: 0.1; UNDERWEIGHT

Height for Age: z score: 0.2; percentile: 57.1; NORMAL

Weight for Age: z score: -2.30; percentile: 1.07

Weight for Height: z score: -3.4; percentile: 0.1; UNDERWEIGHT

 PHYSICAL EXAMINATION
Skin
o Inspection:
(-) jaundice, (-) cyanosis, (-) rashes
o Palpation:
Warm, moist, good mobility and turgor
Nails
o Inspection:
Pinkish, (-) lesions, (-) clubbing
o Palpation:
CRT <2 secs.
 PHYSICAL EXAMINATION
HEENT
Head
o Inspection:
Normocephalic, symmetric, atraumatic, (-) lesions, scalp hair well-distributed
o Palpation:
(-) lumps, (-) masses

Ears
o Inspection:
Symmetrical, (-) gross deformities
o Palpation:
(-) tenderness
o Otoscopy:
Intact tympanic membrane
 PHYSICAL EXAMINATION
Eyes
o Inspection:
Eyebrows - black, (-) scaling, (-) hair loss
Orbital rim - symmetric, (-) swelling
Lid closure - complete
Eyelashes- (-) hair loss, (-) crusting
Sclera - anicteric
Conjunctiva - pink
Cornea - smooth, (-) opacities
Pupils isocoric, (+) direct and consensual pupillary reflex
o Palpation:
Tonometry normal, soft
o Ophthalmoscopy:
(+) ROR on both eyes
o EOM:
Full range of motion
 PHYSICAL EXAMINATION
Nose
o Inspection:
Symmetric, septum in midline, pink nasal mucosa (-) nasal flaring
o Palpation:
(-) pain
Sinuses non-tender

Throat, Mouth and Pharynx

o Inspection:
Lips pink, moist
Oral mucosa pink
Pharynx - (-) exudates
Tongue good color and mobility
 PHYSICAL EXAMINATION
Neck
Inspection:
symmetric, supple
Palpation:
Trachea - midline
Thyroid - not palpabale
Lymph nodes not enlarged

Breast/Axilla/Nodes
Inspection:
(-) lesions, (-) discharge, (-) inflammation
Palpation:
No enlarged lymph nodes
 PHYSICAL EXAMINATION
Chest and Lungs
Inspection:
Symmetric chest walls, (-) gross deformity
Palpation:
(-) mass, (-) tenderness
Percussion:
Resonant in all lung fields
Auscultation:
Clear breath sounds

Cardiovascular
Inspection:
(-) deformities, (-) jugular vein distention
Palpation:
Regular pulses, (-) thrills,
 PHYSICAL EXAMINATION
Percussion:
(-) cardiac border enlargement
Auscultation:
Normal s1 and s2, (-) murmurs

Abdomen
Inspection:
non-protuberant, (-) visible peristalsis, (-) hernia, (-) distention
Palpation:
(-) mass, (-) tenderness, (-) guarding
Percussion:
Tympanitic all throughout
Auscultation:
Normoactive bowel sounds, 25 cpm
 PHYSICAL EXAMINATION
GUT
Inspection:
Grossly female, (-) lesions

Musculoskeletal
Inspection:
(-) gross deformities, (-) swelling
Palpation:
(-) tenderness
Palpable peripheral pulses
 PHYSICAL EXAMINATION
Neurologic
Mental Status
Conscious, alert
Cranial Nerves
II: regards face and able to follow an object with gaze correctly
III, IV, VI: good pupillary reaction to light. Full EOM in the 6 cardinal gazes
with no nystagmus
V: patient is ticklish to light touch and reacts to pain
VII: no facial weakness, face is symmetric
VIII: patient responds to whispered voice
IX, X: uvula is midline, symmetrical elevation of posterior pharynx. No voice
hoarseness
XI: patient can shrug shoulders and turn head
XII: no atrophy or fasciculation in tongue. Tongue is in midline
 PHYSICAL EXAMINATION

Motor
Gait ambulatory, with steady balance and gait
Coordination able to perform finger-to-nose test
Muscle strength: 5/5
Reflexes: 2+
 SUMMARY OF IMPORTANT FINDINGS
5 days PTA, onset of fever
Intermittent, Tmax= 39C

4 days PTA, onset of diarrhea

Watery, green avocado-like, non-blood streaked, non-greasy, foul, 3 cups/episode (total of 3 episodes)

4 hours PTA, onset of vomiting, diarrhea persisted.

non projectile, non blood streaked, non foul smelling, cup per episode, total of 2 episodes, minutes apart.

Associated symptoms:
Irritability
Increased thirst
Anorexia
Disturbed sleep
Slightly sunken eyeballs

(-) Associated symptoms:

Rashes
Lethargy
Cough and colds
 LOGICAL IMPRESSION

ACUTE VIRAL
GASTROENTERITIS WITH
SOME DEHYDRATION
 BASIS FOR IMPRESSION
Fever
Watery diarrhea
Vomiting
Rotavirus common in children
(-) rotavirus vaccination
Irritability
Weakness
Decreased appetite
Slightly sunken eyeball
At 5th hospital day, patient appears well, (-) signs of some
dehydration
DIFFERENTIAL DIAGNOSES RULE IN RULE OUT

(+) fever (-) malaise, myalgia

(+) vomiting (-) chills
Salmonellosis
(+) diarrhea (-) abdominal cramping
Fever usually resolves in 48 hrs
(+) fever
Amoebiasis (-) bloody stool
(+) diarrhea
(+) fever
(-) greasy stool
Giardiasis (+) diarrhea
(-) urticaria
(+) vomiting

(-) abdominal pain followed by vomiting

(-) guarding
(+) fever
(-) pain that warrants staying still
Appendicitis (+) vomiting
(-) Rovsings sign
(+) anorexia
(+) diarrhea

(-) bloating
(-) intesnse abdominal cramping
(+) diarrhea
(-) headache
(+) fever
FOOD POISONING (-) bloody stools
(+) vomiting
(-) erythema nodosum
(-) oral lesions
 ACUTE VIRAL GASTROENTERITIS
Group A rotavirus causes 25-65% of severe infantile gastroenteritis
worldwide.
 ETIOLOGY
Most common viral pathogen : Rotavirus

Infectious in a small inoculum

Person-person contact

Fecal-oral route or by ingestion, of contaminated food or water

Poverty, poor environmental hygiene and development indices

 CLINICAL MANIFESTATIONS
Vomiting

Watery diarrhea

Fever

Temporary lactose intolerance

 MANAGEMENT
Diagnostic
CBC

Fecalysis

Serum electrolytes, BUN, Crea

Rapid Antigen Detection

Urinalysis
 MANAGEMENT
Therapeutic
Adequate IV fluid replacement
Weight: 10 kg
Holiday Segar Formula = 1000ml/kg if 0-10kg
= 1000ml
= 1000 ml/day
W/ some dehydration = 10 X 60
= 600 ml
Total = 1000 ml + 600 ml
= 1, 600 ml/day or 67 ml/hr
Continue Bacillus clausii (Erceflora) 2 billion/5ml oral suspension 2 ampules
per day
DIET: BRAT; no dairy products; DAT afterwards
Continue probiotics (Yakult)
Discharge if stable
 MANAGEMENT
Education
Inform the guardian about the importance of continuing to feed the
patient.

Encourage the guardian to give extra meal a day.

Inform the guardian about the danger signs of diarrhea:

Diarrhea with high fever
Bloody diarrhea
Diarrhea with increased vomiting

Educate the guardian about the importance of good hygiene.

Explain the importance of proper food handling.

 PROGNOSIS
EXCELLENT
THANK YOU