UNIVERSITY OF KUALA LUMPUR
MEDICAL HEALTH SCIENCE & TECHNOLOGY
CASE CLERKING 1
Name: MUHAMMAD IDHAM BIN MOHD ZAN
Matric number: 12107323043
Course code: HMD 21102
Semester: 4
Ward/clinic: Ward 2, PEDIATRIC
PATIENT PARTICULAR
Registered Number: Diagnosis:
31651 ACUTE GASTROENTERITIS WITH MILD
DEHYDRATION
Name:
MUSA BIN MUHAMMAD HAZIQ
Gender: MALE Race: MALAY Occupations: - Age: 11 MONTHS
Address: T3-090-03 LAKEFRONT HOMES, PERSIARAN SEPANG, CYBER11, 63000
CYBERJAYA
Hospital / Clinic: WARD 2 PEDIATRIC, HOSPITAL SLIM RIVER Date: 7TH JUNE 2025
SCENARIO:
New admission received from the emergency department on 7th June 2025@,
09:02 p.m. arrived via ambulance, accompanied by PPK and Parents. His
parents’ complaint that he being vomiting, mild abdominal pain and diarrhea
and he was transferred to triage in yellow zone. He had sick contact with his
elder sister siska 3 years old with AGE disease, and he also had HFMD 2 weeks
ago. General conditions of the patient is alert, mild lethargic due to mild
dehydration with no sunken eyes and capillary refill time <2sec, no tachypnea,
and no tachycardia with temperature 37.4°c and SPO2 99% under room air.
Initial management was giving Normal Saline 80cc bolus and admit to ward 2
from the ED with PPK at 11:40 p.m.
PATIENT HISTORY
I. Chief complaint:
- Vomiting 1/7
- Diarrhea 1/7
II. History of Presenting Complaint:
- Mild dehydrated
- Reduce oral intake
- Mild lethargic
- Less passing urine 1/7 , noted only minimal urine 9p.m
III. Past medical history
- No past medical history
IV. Past surgical history
- No past surgical
V. Family history
- Family has no known medical history
VI. Drug history
- No known drug allergies
VII. Social history
- Mom works as engineer
- Dad works at Sepang
PHYSICAL EXAMINATION
I. General / on examinations
- Alert
- No lack of consciousness
- Mild lethargic
II. VITAL SIGNS
On Arrival
- Blood pressure: 96/56 mmHg
- Pulse rate: 175b/m
- Respiration rate: 28b/m
- Temperature: 37.4°C
- Pain score: 1
- SPO2: 99% under room air.
In Ward
- Blood pressure: 113/62 mmHg
- Pulse rate: 162 bpm
- Respiration rate: 20 b/m
- Temperature: 37.1°C
- Pain score: 0
- SPO2: 96% under room air.
III. GASTROINTESTINAL SYSTEM
- Inspection: No abnormalities
- Percussion: No abnormalities
- Palpation: Soft non tender
- Auscultation: No abnormalities
-
IV. CARDIOVASCULAR SYSTEM
- Dual rhythm, no murmur
V. Central Nervous System
- Eye opening – 4
- Verbal response – 5
- Motor response – 6
Total= 15
VI. Respiration System
- Lungs clear and equal
DIFFERENTIAL DIAGNOSIS
1. Acute Viral Gastroenteritis
• The most common cause is acute viral gastroenteritis, typically caused
by rotavirus or norovirus. This condition often presents with watery
diarrhea, vomiting, fever, and irritability, and is frequently associated
with recent exposure to sick contacts.
2. Bacterial Gastroenteritis
• If the diarrhea is severe, bloody, or accompanied by high fever and toxic
appearance, bacterial gastroenteritis caused by organisms such as
Salmonella, Shigella, or E. coli should be considered, particularly if there
is a history of contaminated food or water exposure.
3. Food Poisoning
• Food poisoning is also possible, especially if multiple family members
show similar symptoms after consuming the same food. It presents with
a rapid onset of vomiting and diarrhea, often without a prolonged
fever.
DIAGNOSIS
- Acute viral gastroenteritis
SIGN & SYMPTOMS
1. Watery stools with no dysentery
2. Vomiting 1/7
3. Mild abdominal cramps or pain
4. Loss of appetite
INVESTIGATIONS
1. PHYSICAL EXAMINATION
- Inspection: No abnormalities
- Percussion: No abnormalities
- Palpation: Soft non tender
- Auscultation: Lungs are clear and equal
2. LABORATORY TEST
FULL BLOOD COUNT
ABNORMAL RESULTS NORMAL RANGE
Hemoglobin (HGB) 9.9 12- 18
White blood count (WBC) 13.6 4.0 - 10.0
Hematocrit (HCT) 42.7 36- 47
Platelets 601 150 – 450
Lymphocytes 50 20 - 48
RENAL PROFILE
ABNORMAL RESULT NORMAL RANGE
Urea nitrogen 5.2 3– 9.2
Sodium 137 L 138 – 145
Potassium 4.5 3.5 – 5.1
Chloride 111 98 – 107
Creatinine 72.8 64 – 111
Phosphate 1.11 0.81 – 1.45
TREATMENT AND MANAGEMENT
1) Monitor Vital Signs
- Keep monitoring Vital Signs such as blood pressure, pulse rate,
respiration rate, temperature, SPO2, pain score Qid.
2) Insert a branula
ON EMERGENCY TREATMENT
- For IV access
- IV Normal Saline 80cc Stat for electrolyte imbalances
ON WARD TREATMENT
- Oral rehydration salt 80ml per purge (loose stool)
- Syrup Paracetamol 125mg PRN
PROGNOSIS
The patient was being treated successfully resulting in an outcome that
appears good. The patient continues with conservative treatment and
discharges on 8th June 2025.
