CASE

PRESENTATION--
AGE
BY
RAWAT, PRINCE PASCAL AND JALANDRE SIMRAN
 Outline of the Presentation

01 History 04 Differential Diagnosis

Salient Features
02 Physical Exam Course in the Wards 05
03 Case Discussion 06
01 HISTORY
 GENERAL DATA
● Patient: L.K.H.
● Age: 1 year old
● Gender: Female
● Race: Filipino
● Religion: Roman Catholic
● DOB: 6th sept. 2022
● Address: Manga, Tagbilaran city, Bohol
● Admitted: 10/06/23
● Informant: Mother
● Reliability: 95%
● 1st consult
CHIEF COMPLAINT
 Fever and Loose bowel movement
HISTORY OF PRESENT ILLNESS
2 Days PTA
• Onset of loose bowel movement *5 episodes nonbloody, nonmucoid,
and intermittent undocumented fever for which paracetamol 5mls was
given and provided temporary relief.

1 Day PTA
 Still with loose bowel movement *5 episodes, now associated with
vomiting *4 episodes.

On the day of admission

 Persistence of loose bowel movements ×8 episodes, approximately 1
cup per episode, nonbloody, nonmucoid and associated with
vomiting of 2 episodes composed of previously taken milk and on
and off fever, TMax= 38.1C
PRENATAL HISTORY
Maternal Age: 23 y.o.
OB Score: G2 P2 (F2 P0 A0 L2)
Address: MANGA, Bohol.

First prenatal check-up at: 1 mos

No. of visits: 8
Consult with midwife at local health center
Vitamins and supplements: Folic Acid, Multivitamins
Vaccinations: TT, Covid-19 (Sinovac x 2 doses)
Smoking/Alcoholic: NA
Heredofamilial Disease: Maternal side- Hypertension and Diabetes
mellitus
Maternal Illness: None
Blood type: “B+”
 NATAL HISTORY
 Place of delivery: GCGMMC
 BW: 2.5kgs
 Date of delivery: 09/06/2022
 Length: 48 cm
 Birth order: 2
 Vaccines and meds given:
 Manner of delivery: NSVD
 BCG and Hep B, vitamin K,
Presentation: Cephalic
 Erythromycin eye
Received: Full term, 37 weeks
 prophylaxis
Ballard Score: 37 weeks
 Maternal illness: none
 AS: 8,9
 Attendant: Doctor
POSTNATAL HISTORY
Condition on delivery: Term looking, no cord coil, non meconium
stained, no jaundice.

No resuscitation done.
No antibiotics given.
No complications.
FEEDING HISTORY
0-6 months: exclusively breastfed
6-12 months- Mixed feeding:
 1:1 breastfeeding and Milk formula

6 months old- semisolid food started (cerelac)

IMMUNIZATION HISTORY
Complete as per age according to mother.
 FAMILY HISTORY
Mother: J.O
Age:23 year old
Occupation: Housewife
Educational attainment: College graduate
Currently well

Father: R,J.
Age: 29 yo.
Educational attainment: College graduate
Occupation: private job
Currently well

Siblings
1 elder brother, 3 years old, healthy
PAST MEDICAL HISTORY
No past illnesses.
No past hospitalizations.
No known food and drug allergies

TRAVEL HISTORY- no recent travel history

 PHYSICAL
02 EXAMINATION
PHYSICAL EXAMINATION
VITAL SIGNS:
 PR:141 bpm Weight-8 kgs
 RR:27 cpm Temp: 38.6
 O2 sat: 98 % at room air

 S: (+) fever (+) diarrhea (+) vomiting (-) cough (-) coryza
 O: Awake, alert, irritable, not in respiratory distress
 Skin: no rash, no jaundice, no cyanosis, moderate skin turgor,
warm to touch
 HEENT: anicteric sclerae, pink palpabral conjunctiva, slightly
sunken eyeballs, dry lips, no nasal discharge
 NECK: (-) mass (-) lymphadenopahy
 BREAST: (-) mass
 C/L: equal chest expansion, (-) retractions, clear breath sounds
 CVS: adynamic precordium, distinct heart sounds, (-) murmurs
03 SALIENT FEATURES
SALIENT FEATURES
 1 year old
 (+) fever
 (+) slightly sunken eyeballs
 (+) dry lips
 (+) loose bowel movement, non-bloody, non-mucoid
 (+) vomiting
INITIAL DIAGNOSIS:
ACUTE GASTROENTERITIS
WITH MODERATE DEHYDRATION
 DIFFERENTIAL
04 DIAGNOSIS
DIFFERENTIAL DIAGNOSIS
DIFFERENTIALS RULE IN RULE OUT

1. INTESTINAL AMOEBIASIS Rare under 2 years of age

(ENTAMOEBA HISTOLYTICA Fever Blood streak stools, mucoid
INFECTION) Diarrhea Foul smelling
Loose watery stools Gradual onset (Incubation period: 2-4
weeks)

2. BACTERIAL ENTERITIS Age: Children younger than 5 years old Bloody Diarrhea
(NON TYPHOIDAL SALMONELLA Vomiting Abdominal cramps
INFECTION) Fever
Acute onset (1-5 days)

3. SMALL BOWEL Common in young age Non billious vomiting

OBSTRUCTION(INTUSSESPTION) Fever Bloody Diarrhea
vomiting
05 COURSE IN THE WARDS
Patient was admitted for 3 days under service of Dr. Torregosa
ER: October 6,2023
S O A P
(+) fever Gen: Awake, Irritable, NIRD Acute Gastroenteritis with >Admit to pedia ward under
(+) vomiting Skin: Warm to touch with Moderate Dehydration service of Dr. Torregosa
(+) diarrhea moderate skin turgor >Give IVF start PLR 500 cc st 60
HEENT: : anicteric sclerae, pink cc/hr
palpabral conjunctiva, sunken >IV to follow D5IMB 500 cc at 60
eyeballs, dry lips, no nasal cc/hr
discharge Labs:
C/L: equal chest expansion, (-) *CBC, Urinalysis
retractions, clear breath sounds Serum. Na, K, Creatinine, Dengue
CVS: adynamic precordium, duo,
distinct heart sounds, (-) *Stool Exam
murmurs
ABD: soft, non-distended, Medications
normal active bowel sounds, (-) 1.ORS sachet mix 1 sachet to 200
masses mL water. Give sip by sip of
EXT: (-) edema, capillary refill volume per volume replacement
time <2 secs, strong peripheral 2. Paracetamol 1.2ml oral drops
pulses every 4 hours
3. Zinc drops 2ml per oral once a
PR:141 bpm day
Weight-8 kgs > Monitor vital signs q4 hours
RR:27 cpm > Strict I&O monitoring
Temp: 38.6 > Refer accordingly
O2 sat: 98 % at room air
 Hospital Day 1: October 07, 2023
S O A P

(+) Diarrhea Gen:Asleep, comfortable, NIRD Acute Gastroenteritis with Give Diet as tolerated
(+)Fever Skin: Warm to touch with Moderate Dehydration >IVF to follow D5IMB 500 cc at
(+) Vomit moderate skin turgor 30 cc/hr
(+) Good cry HEENT: : anicteric sclerae, pink > Continue meds—
(+) Good suck palpabral conjunctiva, sunken ORS for volume/volume
(+) Urine Output eyeballs, dry lips, no nasal replacement.
(+) Good activity discharge Zinc drops 2ml orally once a day
C/L: equal chest expansion, (-) Paracetamol 1.2ml orally every 4
retractions, clear breath sounds hours for temperature more than
CVS: adynamic precordium,
or equal to 38degrees C
distinct heart sounds, (-) murmurs
ABD: soft, non-distended, normal
active bowel sounds, (-) masses
EXT: (-) edema, capillary refill
time <2 secs, strong peripheral
pulses
Vital Signs:
PR:127 bpm
RR:33 cpm
Temp: 37.2
O2 sat: 98 % at room air
 Hospital Day 2: October 08,2023
S O A P

(-) Fever Gen:Asleep, comfortable, NIRD Acute Gastroenteritis with >May go home today
(-) loose bowel movement Skin: Warm to touch with good moderat Dehydration- > Take home medication:
(-) vomit skin turgor IMPROVED 1. ORS sachet mix 1 sachet to 200
Good activity HEENT: : anicteric sclerae, pink mL water. Give sip by sip of
No signs of dehydrarion palpabral conjunctiva, non-sunken volume per volume
(+) UO eyeballs, moist lips, no nasal replacement.
discharge 2. Zinc drops 2ml per oral once a
C/L: equal chest expansion, (-) day
retractions, clear breath sounds
CVS: adynamic precordium, > Advice proper handling of feeding
distinct heart sounds, (-) murmurs bottles
ABD: soft, non-distended, normal > Advice proper disposal of diapers.
active bowel sounds, (-) masses > Follow up if symptpms reappear of
EXT: (-) edema, capillary refill any other unusualties at Pedia OPD.
time <2 secs, strong peripheral
pulses

Vital Signs:
Pulse Rate: 121 bpm
RR: 28 cpm
Temp: 36.7
02 sat.- 99% at room air
LABORATORY RESULTS--
Stool Exam - October 7,2023
PARAMETERS RESULT UNIT

Macroscopic
● Color Greenish
● Consistency Soft

Microscopic
● WBC Not seen PER HPF
● RBC Not seen PER HPF

Parasite
● Ova Not seen
● Cyst Not seen
● Trophozoites Not seen
● Bacteria FEW
CBC – October 6,2023
WBC 10.90 4.6 - 10.2 x10^9/L

Hemoglobin 126 122-162 g/L

Platelet 318 142-424 x10^9/L

Differential count
Neutrophils 0.31 0.37-0.80 ng/L
Lymphocytes 0.62 0.10-0.50 ng/L
Monocytes 0.06 0.0-0.12 ng/L
Eosinophils 0.00 0.00-0.07 ng/L
Basophils 0.01 0.000-0.025 ng/L
CHEMISTRY RESULTS Oct. 06, 2023
PARAMETER RESULT NORMAL VALUES
Creatinine 45.08 53.0-106 mg/dL
Potassium 4.58 3.5 - 5 mEq/L
Sodium 135 135-145 mEq/L
Urinalysis - September 22, 2023
Red blood Cells 5 0-11 /ul
White blood cells 0.9 0-17 /ul
Epithelial cells 01 0-28 /ul
Bacteria 24 0-340 /ul
Color Straw
Transparency Clear
ph 7.0
Specific gravity 1.015
Blood Negative
Leukocyte Negative
Final Diagnosis:
Acute Gastroenteritis with Moderate
dehydration
CASE DISCUSSION
 EPIDEMIOLOGY
RISK FACTORS RELATED TO ECONOMIC DEVELOPMENT
 Insufficient access to adequate hygiene, sanitation, and clean drinking water

ENDEMIC DIARRHEA
 In the US, Rotavirus was the most common cause of medically attended AGE among children younger
than 5 years of age

FOODBORNE TRANSMISSION
 Among children 0-19 yr of age: NTS was the most common, followed by Campylobacter and Shigella,
then STEC and Cryptosporidium.
 Least common: Vibrio, Yersinia, Cyclospora

NOSOCOMIAL DIARRHEA
 Most common cause of healthcare-associated infection in the US: C. difficile
 Predisposing factors: recent antibiotics, gastric acid suppression, immunosuppression, gastrointestinal
comorbidities

Reference: Nelson Textbook of Pediatrics, 21st Edition. Chapter 366: Acute Gastroenteritis
 EPIDEMIOLOGY
ZOONOTIC TRANSMISSIONS
 NTS: transovarian passage in hens allows infection of intact grade A
pasteurized eggs
 Campylobacter: major cause of sporadic bacterial foodborne disease
in industrialized countries, usually from consumption of
contaminated chicken, meat, beef, and milk

SEASONALITY
 Rotavirus and norovirus: peak in cool seasons
 Enteric adenovirus infections: occur throughout the year, with some
increase in summer
 Salmonella, Shigella, and Campylobacter: favor warm weather
 Yersinia: tolerate cold manifests as a winter seasonality, ability to
survive
Reference: Nelson Textbook ofin contaminated
Pediatrics, 21st Edition. Chapter blood products during refrigeration
366: Acute Gastroenteritis
 PATHOGENESIS

Reference: Nelson Textbook of Pediatrics, 21st Edition. Chapter 366: Acute Gastroenteritis
 CLINICAL MANIFESTATIONS
VIRAL DIARRHEA
 Rotavirus AGE
 usually begin with vomiting followed by frequent passage of watery non-bloody
stools. Assoc with fever in about half the cases
 Recovery with complete resolution of symptoms generally occurs within 7 days

 Calicivirus AGE
 Brief incubation period (12-48 hr) with short duration of illness

 Enteric adenovirus AGE

 More prolonged (7-10 days)

 Astroviruses AGE
 Shorter course (~5 days) without significant vomiting

Reference: Nelson Textbook of Pediatrics, 21st Edition. Chapter 366: Acute Gastroenteritis
 CLINICAL MANIFESTATIONS
BACTERIAL DIARRHEA
 Common manifestations: fever >40C, overt fecal blood, abdominal pain,
no vomiting before diarrhea onset, high stool onset (>10 per day)

The classic bacterial agents (NTS, Shigella, Campylobacter and Yersinia)

present with 1 of 5 syndromes:

1. ACUTE DIARRHEA
 Most common presentation
 May be accompanied by fever and vomiting

1. BLOODY DIARRHEA OR FRANK DYSENTERY

Nelson
Reference: Watery
Textbook ofdiarrhea typically
Pediatrics, 21st Edition. precedes
Chapter 366: dysentery and often the sole clinical
Acute Gastroenteritis
 CLINICAL MANIFESTATIONS
4. EXTRAINTESTINAL INVASIVE INFECTIONS
From either local invasion or bacteremic spread

5. VERTICAL TRANSMISSION of Shigella, NTS and

Campylobacter
Can produce perinatal infection

Reference: Nelson Textbook of Pediatrics, 21st Edition. Chapter 366: Acute Gastroenteritis
 CLINICAL MANIFESTATIONS
C. difficile
 Most common mild-moderate watery diarrhea, low-grade fever, and mild abdominal
pain
 Pseudomembranous colitis
 Characterized by diarrhea, abdominal cramps and fever

PROTOZOAL DIARRHEA
 Tend to be more prolonged, sometimes for 2 weeks or more
 Usually self-limited in the otherwise healthy host
 Protozoal etiology should be suspected when there is a prolonged diarrheal illness
characterized by episodes of sometimes explosive diarrhea with nausea, abdominal
cramps and abdominal bloating
 Stools are usually watery but can be greasy and foul smelling

Reference: Nelson Textbook of Pediatrics, 21st Edition. Chapter 366: Acute Gastroenteritis
DIAGNOSTICS
Initial Evaluation of diarrhea

Reference: Nelson Textbook of Pediatrics, 21st Edition. Chapter

366: Acute Gastroenteritis
Physical signs
 General Appearance (activity and stimulation)
 Skin Turgor Assessment
 Capillary refill time
 Assessment of mucous membrane(moisture level, presence of tears
and extremity temperature)

Reference: Nelson Textbook of Pediatrics, 21st Edition. Chapter

366: Acute Gastroenteritis
MANAGEMENT
 The broad principles of management of AGE in children:
 Rehydration
 Maintenance ORS plus replacement of continued losses in diarrheal stools and
vomitus after rehydration
 Continued breastfeeding, and refeeding with an age-appropriate, unrestricted
diet as soon as dehydration is corrected.
 Zinc supplementation is recommended for children in developing countries.
 Dehydration must be evaluated rapidly and corrected in 4-6 hr according to the degree
of dehydration and estimated daily requirements.
 ORS containing 75 mEq of sodium, 64 mEq of chloride, 20 mEq of potassium, and 75
mmol of glucose per liter, with total osmolarity of 245 mOsm/L, is now the global
standard of care - approved by WHO
 Soda beverages, fruit juices, tea, and other home fluids are not suitable for rehydration
or maintenance therapy because they have inappropriately high glucose concentration
and osmolalities and low sodium concentrations. .

Reff: Nelson 366

 Reff: WHO ; treatment of diarrhea 2005
hydration status of the patient

Reference: Nelson Textbook of Pediatrics, 21st Edition. Chapter 366: Acute

Gastroenteritis
Clinical practice guidelines
Philippines Protocol for
Rehydration
Antibiotic therapy
for Infectious Diarrhea
PREVENTION
1. Drinking water should be clean and safe.
2. Wash raw foods. Cook food well. Store foods properly.
3. Diligent hand washing, particularly after touching surfaces in public
or after going to the toilet. Ideally, use liquid soap in running water,
but any soap is better than none. Dry properly after washing. Use of
hand sanitizer that contains at least 70% alcohol is a reasonable
alternative if the hands are not visibly dirty.
4. Rotavirus Immunization
5. All efforts should be made to get access to clean water, soap and
hand drying materials.
6. Safe stool disposal and hand hygiene should always be practice.
PROGNOSIS
 Gastroenteritis is usually resolved within 2 to 3 days and there are no long-term
effects. If dehydration occurs, recovery is extended by a few days
 Underlying cause: The prognosis may be influenced by the specific causative
agent of gastroenteritis. Bacterial or parasitic infections may require targeted
antimicrobial or antiparasitic treatments, while viral gastroenteritis is typically
self-limiting and resolves without specific antiviral treatment
Thank you,
Doctors!
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