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Case Presentation
B. J.
3 year old
Male
Roman Catholic
Address: Urgello, Cebu
Date of Birth: December 01, 2014
Place of Birth: Cebu City
Admitted at CDUH on December 11, 2017
Chief complaint
Bloody Diarrhea
History of Present Illness
1 Day PTA
2 Days PTA
10 episodes of Diarrhea
• Foul smelling
Baby wasn’t able to eat or
• yellowish
drink, was given with tap
• mucoid
water.
• bloody
• ~ 1 cup per episode
Brought to Sacred Heart
Fever Tmax 38.5C
Center ER (+) tonsilitis
Given Co-amoxiclav 4ml
Management: No meds given
3x a day by the ER
Physician
Associated Symptom:
Weakness
No Associated Symptoms:
Anorexia
•fever
Irritability
• cough
(-)changes in urination, sleeping
• chills
pattern
2 hours PTA
2 episodes of Diarrhea
• ~1 cups per episode
• same character
Management: ORS
(1000 ml)
Associated Symptom:
Anorexia
Weakness
(-)fever
(-)changes in urination,
sleeping pattern
Pre-natal History
• No previous hospitalizations
• No food or drug allergies
Family/ Medical History
• VITAL SIGNS
• HR – 121 bpm; apical pulse
• RR - 28 cpm
• BP – 80/60 mmHg
• Temp – 36oC/ Right axilla
• ANTHROPOMETRIC MEASUREMENTS
• Height: 105 cm z-score= 2 HC: 53.5 cm
• Weight: 13kg z-score= -1 CC: 55 cm
AC: 54cm
SKIN:
Inspection:
Fair complexion, (-) jaundice, (-) cyanosis, (+) rashes
Palpation:
Cool, dry
poor turgor
HEAD:
Inspection:
• Symmetric, normocephalic, atraumatic
• Scalp hair well-distributed
• No dilated scalp veins, no scaling, no rashes
Palpation:
• No lumps noted, no masses , no tenderness
Percussion:
• No facial grimacing upon tapping of cheek
(-) Chvostek's sign
EYES:
Inspection:
• Anicteric sclera, (-) conjunctival redness, (-) lens
opacities, pupils isocoric
• Sunken eyeballs
• Complete lid closure,
• Full extraocular movements, OU, no nystagmus
• (+) ROR
Palpation:
• No tenderness around orbital rim
• Good rebound pressure
EARS :
Inspection:
• Both pinnae in line with lateral canthus
• (-) gross deformities, (-) lesions,
• Blinks eyes in response to sudden sharp sound
or voice
• intact typmanic membrane with minimal moist
cerumen, (-) inflammation, (-) foreign body, no
discharges
Palpation:
• No tenderness, no masses
NOSE and PARANASAL SINUSES:
Inspection:
• Symmetric, septum at midline, pink nasal mucosa
• No secretions, no inflammation, no alar flaring
Palpation:
• No tenderness over maxillary and frontal sinuses
ORAL CAVITY/THROAT:
Inspection:
• Dry lips
• pink oral and buccal mucosa,
• dentition: all upper and lower central and lateral incisors fully erupted
upper left first molar partially erupted
• Tongue midline, uvula midline, no exudates
Palpation: Intact hard palate,
NECK:
Inspection: symmetric, no webbing, supple
Palpation:
• trachea midline, thyroid cartilage midline
• No palpable lymph nodes, no masses
Inspection:
• Protuberant, symmetric, slightly visible blood
vessels, inverted umbilicus with no signs of
inflammation, no hernia, no dilated veins, no
rashes, not distended
Palpation:
• Liver and spleen edge non palpable; aortic
pulsations felt
• Non-sensitive, non tender
Percussion: tympanitic throughout
Auscultation: hyperactive bowel sounds
GUT:
Inspection:
• Grossly male, foreskin completely covers glans
penis, penis straight, scrotum with rugae
• Tanner Stage 1
• No swelling, no rashes
Palpation:
• No tenderness, both testes inside scrotal sacs
• No masses
EXTREMITIES:
Inspection
• No gross deformities, no signs of inflammation
• No cyanosis, no ulceration, no hip dislocation
• Full range of motion in all limbs
Palpation:
• No tenderness
• Palpable, tapping peripheral pulses
SENSORIUM: awake, not crying
CRANIAL NERVES:
I- not done
II – regards face
III, IV, VI – blinks in response to light, equally rounded pupils,
reactive to light,
(+) consensual and direct pupillary light reflex OU
extraocular movments full in all 6 directions
V – responds to touch on cheek, tickled by cotton
VII – no facial asymmetry
VIII – responds to voices, tracks sound,
IX, X – able to swallow
XI – symmetrical shoulders, able to shrug
XII – tongue midline
MOTOR:
• good muscle tone, no tremors, strong grasp
SENSORY: reacts to soft touch on face symmetrically
REFLEXES:
• 2+ throughout
CEREBELLAR: active spontaneous movement
MENINGEAL SIGNS:
(-) Brudzinski's sign, (-) Kernig's sign
Summary of Important Findings
• 2 days of acute bloody diarrhea
• Given tap water to drink
• weakness
• anorexia
• random foods (any family members hand to the patient sometimes
without regards with sanitation)
• Recent weight change
• Dry skin
• Sunken Eyeballs
• hyperactive bowel sounds
Differential Diagnosis
Rule in Rule out
Amebic Dysentery + frequent bowel movement (-) vomiting
+ age (common in 1-4 y/o) + fever
+ common in tropical countries Incubation period is within1-8 days
+ bloody stool
Cholera +fatigue, anorexia + bloody stool
+abdominal pain (-) vomiting
+diarrhea
+dehydration
Acute Viral Gastroenteritis + diarrhea (-) vomiting
(Rotavirus infection) + fever + bloody stool
+ abdominal pain
• Fecal-oral route
• Ingestion of Contaminated water and food
• Person to person contact
Risk factors
• Fever
• Vomiting
• Diarrhea
• Reduced oral intake
• Abdominal pain
• Sign and symptoms of dehydration
Etiology
• Epidemiology
– Most common infection in 2nd and 3rd years of life
– 70% of all episodes and 60% of all Shigella-related deaths
involve younger than 5 years old
– Breast milk contains antibodies to plasmid-coded antigens and
lipopolysaccharides
– Occurs during rainy months in tropical climates
Pathogenesis
Diagnostic Tests
– CBC
– Urinalysis
– Stool analysis
• Fecal leukocytes
• Occult blood
• Stool culture
• Stool microscopy
– Serum electrolytes, BUN, creatinine
Therapeutic
– Monitor Vital Signs q4h
– ORS
• mild-moderate dehydration – 575-1150 mL over 3-4 hours (rehydration); 120-240 mL for each diarrheal
episode (replacement of losses)