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PAC 6016
ACUTE
GASTROENTERITIS
PATIENT IDENTIFICATION
CHIEF COMPLAIN
Patient came to Hospital Temerloh due to vomiting and diarrhea four days prior to
admission
was released back home after the fever went down and accompanied with ORS and
antipyrexia.
On the next few day, the symptoms still present but there was improvement.
However, he started to complain abdominal pain and relieved when defecate. There
was no fever. At that time, he started to have fatigue and not active.
On 26th November 2014, he had vomiting ten times with minimal amount. The
contents was only fluid and no blood stain. The diarrhea still persist but not severe as
before with same presentation as before. As the result he was brought to Hospital
Jerantut, in emergency department he was given oral rehydration salt and transfer to
Hospital Temerloh for further management.
Since admission, he was treated with ORS and several type of antibiotic.
According to his mother, there were changes of antibiotic due to the aggravated of
vomiting in 1st introduction and the 2nd and 3rd times the fever still persist. Since the 4th
antibiotic was given, the child respond well with it as evidence of no fever and no
vomiting.
SYSTEMIC REVIEW
Cardiovascular system
- no palpitation
- no chest pain
Respiratory system
- no shortness of breath
- no cough
Genitourinary system
-no dysuria
-no oliguria
PAST MEDICAL HISTORY/PAST SURGICAL HISTORY
OBSTETRIC HISTORY
Antenatal history
Mother did not developed any illnesses during antenatal period such as fever,
rash, gestational diabetes mellitus and hypertension.
Birth history
He was born in term via spontaneous vagina delivery with a birth weight of 3.1
Kg. There was no complication during birth and after birth
IMMUNIZATION HISTORY
Social : Able to dress himself with the help of mother, able to button
and unbutton himself
FAMILY HISTORY
He is the youngest child out of four siblings. The eldest is 18 years old female, the
second is 16 years old female , the third is 12 years old boy. His father was
hypertension since 12 years ago and on medication.
DIET HISTORY
DRUG HISTORY
None
SUMMARY
A 3 years 2 month old malay boy presented to Hospital Temerloh with vomiting and
diarrhea 4 days prior to admission. There was history of abdominal pain and tenesmus.
However, there was no history of taking outside food
PHYSICAL EXAMINATION
GENERAL EXAMINATION
Inspection
Patient was lying supine comfortably. His behavior was appropriate for his age
and he was not irritable. He was alert, in tachypnea and looked restless. There was a
cannula attached to his left arm connected to IV normal saline.
Vital sign
Anthropometric measurement
Height : 96 cm
Weight : 11.3 kg
As the result , the height centile is within 25-50 centile and for the weight is below 3 rd
centile.
Hand
Head
Leg
There was no pitting edema
SPECIFIC EXAMINATION
Abdominal Examination
On inspection
The abdomen was not distended, move with respiration, the umbilical was
centrally located, no surgical scars and visible vein noted
On palpation
On Auscultation
The bowel sound was normal and no renal bruit
Cardiovascular examination
On Inspection
The chest move with respiration. There was no scar and dilated vein.
On Palpation
Apex beat is at left fifth intercostal space at midclavicular line, jugular venous
pressure was not raised, there was no parasternal heave and no palpable thrill
On Auscultation
First heart sound and second heart sound was heard and there was no added
sound heard
Respiratory examination
Inspection
On Palpation
Apex beat : left 5th intercostals space at midclavicular line, trachea is centrally
located, chest expansion was normal and vocal fremitus was normal.
On Percussion
On Auscultation
PROVISIONAL DIAGNOSIS
Based from the history of the symptoms of generalized colicky abdominal pain
associated with several episodes of diarrhea and vomiting is the typical features for
Acute gastroenteritis. On systemic review, this patient has no other problems that can
excude the AGE. Regarding the clinical findings, generally revealed signs that indicate
dehydration, otherwise the other systems were all in normal limit. Therefore, this is most
likely diagnosis.
DIFFERENTIAL DIAGNOSIS
1.Acute appendicitis
Point for : vomitting and abdominal pain
Point against : usually not assocated with diarrhea
2. Small bowel obstruction :
Point for : vomiting and diarrhea
Point against : the vomitus was not bile-stained, the abdominal pain was not
Severe and not blood stained.
3,Dengue Fever
Point for : has fever, abdominal pain and fatigue
Point against : no rashes, no myalgia, no retro-orbital pain, no athralgia
INVESTIGATION
Result :
4.Stool FEME
Reason: To look for any occult blood loss and look for organism involved
Result : Negative
Creatinine : 85 mmol/L
Uric acid : 395 mmol/L
Interpretation: It has normal ratio of urea and creatinine, so there was no acute
kidney injury.
MANAGEMENT
The principle management of acute gastroenteritis is about to correct the fluid
and electrolytes imbalance. This is because the patient have loss of fluid and
electrolytes due to diarrhea and vomiting. In severe case, it may lead to metabolic
acidosis due to severe dehydration.
First of all, we must monitor vital signs such as blood pressure, respiratory rate
and heart rate. In addition, we must monitor input and output chart. These steps should
be done to prevent hypovolemic shock.
In this case, the patient was put under mild dehydration. For mild dehydration, we
should manage him by giving a trial of oral rehydration solution (ORS) 40-60 mL/Kg
within 4-6 hours, then replace with 10 mL/kg of ORS every diarrhea episode. He must
be feed normally.
We started the antibiotic once we got the result of blood cultures and sensitivity
that revealed what types of organism it was. The common antibiotics used are
tetracycline and erythromycin.
DISCUSSION
Acute gastroenteritis accounts for millions of deaths each year in young children,
mostly in developing communities. In developed countries it is a common reason for
presentation to general practice or emergency departments and for admission to
hospital. Dehydration, which may be associated with electrolyte disturbance and
metabolic acidosis, is the most frequent and dangerous complication.
The patient better to be treated in the ward. There are few indication of
admission such as need for intravenous therapy, uncertain of diagnosis so the work up
are needed to find the causes, patient factors for example patient is too young and
worsening of symptoms, caregiver unable to give full commitment to take care of the
children and social and logistic factor such as too far away from hospital and hard to
return back if something bad happen such as worsening of vomiting and diarrhea.
REFERENCE
1. Paediatric Notes