PEDIATRIC CASE PRESENTATION KHO, ROSCELIE L. PDR 3 BLOCK 2
AUGUST A UGUST 23, 2016 at 2:30pm 2:30pm
Maternal Grandmother and Maternal Aunt
93%
GENERAL DATA •
K.B. 2 years old, Male
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Filipino
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Roman Catholic
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Address: Upper Laguerta, Busay Busay
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DOB: January 14, 2014
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POB: Upper Laguerta, Busay
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1st admission at CDUH; August 20, 2016
CHIEF COMPLAINT DIARRHEA
HISTORY OF PRESENT ILLNESS •
5 days PTA •
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Intermittent low grade fever, Tmax: 39 oC Paracetamol (Calpol) 120mg/5ml, 1 ½ tsp (7.5ml) q4H, total of 3 doses, temporary relief, temperature not measured after administration. Negative Negative of associated symptoms: •
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Cold Cough Rashes Abdominal pain Diarrhea Lethargy Vomiting
HISTORY OF PRESENT ILLNESS •
4 days PTA •
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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, ½ cup, 2 doses; no relief. Associated symptoms: • • • •
Increase thirst Poor appetite Slight irritability Disturbed sleep
HISTORY OF PRESENT ILLNESS •
4 hours PTA •
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•
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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, ½ cup per episode, total of 2 episodes, minutes apart. Associated symptoms: •
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Sunken eyeballs Irritability Increased thirst Poor appetite Disturbed sleep
PRE-NATAL HISTORY •
Mother, 25 years old, G2P1 (1001)
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Pre-natal care: • •
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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
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Vitamins: unrecalled.
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Immunizations: unrecalled.
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(+) alcoholic beverages, (-) smoking
POST NATAL HISTORY •
Full term 37 wks AOG
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Birth rank: 2/2
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NSVD
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Home Delivery, midwife
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Good cry
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Birth weight: 2700g (estimated)
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No complications noted
FEEDING HISTORY •
Exclusive breastfeeding for 2 weeks.
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Formula feeding: Enfalac: up to 6 months Promil: up to 1 year Progress Gold: up to 2 years Bear brand/ Nido at present.
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Semi solid food: 4-5 months old
GROWTH AND DEVELOPMENT •
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2 months old •
Social smile
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Head control in prone position
3 months old •
Lifts head and chest with arms extended
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Sustained social contact
4 months old •
Laughs
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Reaches and grabs objects and places them in mouth
GROWTH AND DEVELOPMENT
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5 months old •
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6 months old •
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Transfers object from hand to hand
Sits with support
7 months old •
Responds to tone of voice
GROWTH AND DEVELOPMENT
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12 months old •
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Stands alone
24 months old •
Combines 2 words
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Can imitate actions
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Understand simple instructions
IMMUNIZATION HISTORY
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BCG and Hep B 1st dose: at birth
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Received at health center: •
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Hepatitis B second dose: 1 month old DPT, OPV, Hib: •
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•
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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 •
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1ST Vicente Sotto Memorial Medical Center •
Mid September 2015
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Age 1
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Pneumonia
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Discharged after 3 weeks
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Without complications
Denies any form of allergy.
FAMILY HISTORY •
Mother: 26 years old, deceased, cardiac arrest from unknown medication.
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Father: whereabouts unknown.
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Sibling: •
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4 years old, male, alive and well.
Heredofamilial disease: •
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Diabetes mellitus Hypertension Stroke
PERSONAL AND SOCIAL HISTORY •
Mother deceased, 1 year ago.
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Resides at maternal aunt and grandmother’s house.
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Maternal grandmother is legal guardian.
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Purified water for drinking.
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Describes living in a well knit, peaceful community.
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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 sore’s on the penis, testicular pain or masses, history of sexually transmitted diseases and their treatments. Sexual habits, interest, function, satisfaction, birth control methods,
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
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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: •
o
Palpation: •
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(-) jaundice, (-) cyanosis, (-) rashes Warm, moist, good mobility and turgor
Nails o
Inspection: •
o
Pinkish, (-) lesions, (-) clubbing
Palpation: •
CRT <2 secs.
PHYSICAL EXAMINATION HEENT
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Head Inspection:
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Normocephalic, symmetric, atraumatic, (-) lesions, scalp hair well-distributed
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Palpation:
o
(-) lumps, (-) masses
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Ears Inspection:
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Symmetrical, (-) gross deformities
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Palpation:
o
(-) tenderness
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Otoscopy:
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Intact tympanic membrane
PHYSICAL EXAMINATION •
Eyes o
o
Inspection: •
Eyebrows - black, (-) scaling, (-) hair loss
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Orbital rim - symmetric, (-) swelling
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Lid closure - complete
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Eyelashes- (-) hair loss, (-) crusting
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Sclera - anicteric
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Conjunctiva - pink
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Cornea - smooth, (-) opacities
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Pupils – isocoric, (+) direct and consensual pupillary reflex
Palpation: •
o
Ophthalmoscopy: •
o
Tonometry – normal, soft
(+) ROR on both eyes
EOM:
PHYSICAL EXAMINATION •
Nose Inspection: Symmetric, septum in midline, pink nasal mucosa (-) nasal flaring o Palpation: (-) pain Sinuses non-tender o
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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 •
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Breast/Axilla/Nodes Inspection: (-) lesions, (-) discharge, (-) inflammation Palpation: No enlarged lymph nodes •
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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
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Palpable peripheral pulses
PHYSICAL EXAMINATION Neurologic •
Mental Status •
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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
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Motor •
Gait – ambulatory, with steady balance and gait
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Coordination – able to perform finger-to-nose test
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Muscle strength: 5/5
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Reflexes: 2+
SUMMARY OF IMPORTANT FINDINGS •
5 days PTA, onset of fever •
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4 days PTA, onset of diarrhea •
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non projectile, non blood streaked, non foul smelling, ½ cup per episode, total of 2 episodes, minutes apart.
Associated symptoms: •
Irritability
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Increased thirst
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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. •
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Intermittent, Tmax= 39 °C
Anorexia
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Disturbed sleep
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Slightly sunken eyeballs
(-) Associated symptoms: •
Rashes
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Lethargy
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Cough and colds
LOGICAL IMPRESSION
ACUTE VIRAL GASTROENTERITIS WITH SOME DEHYDRATION
BASIS FOR IMPRESSION •
Fever
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Watery diarrhea
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Vomiting
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Rotavirus common in children
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(-) rotavirus vaccination
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Irritability
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Weakness
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Decreased appetite
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Slightly sunken eyeball
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At 5th hospital day, patient appears well, (-) signs of some dehydration
Salmonellosis
(+) fever (+) vomiting (+) diarrhea
(-) malaise, myalgia (-) chills (-) abdominal cramping Fever usually resolves in 48 hrs
Amoebiasis
(+) fever (+) diarrhea
(-) bloody stool
Giardiasis
(+) fever (+) diarrhea (+) vomiting
(-) greasy stool (-) urticaria
Appendicitis
FOOD POISONING
(+) fever (+) vomiting (+) anorexia
(+) diarrhea (+) fever (+) vomiting
(-) abdominal pain followed by vomiting (-) guarding (-) pain that warrants staying still (-) Rovsing’s sign (+) diarrhea
(-) bloating (-) intesnse abdominal cramping (-) headache (-) bloody stools (-) erythema nodosum (-) oral lesions
ACUTE VIRAL GASTROENTERITIS •
Group A rotavirus causes 25-65% of severe infantile gastroenteritis worldwide.
ETIOLOGY •
Most common viral pathogen : Rotavirus
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Infectious in a small inoculum
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Person-person contact
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Fecal-oral route or by ingestion, of contaminated food or water
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Poverty, poor environmental hygiene and development indices
CLINICAL MANIFESTATIONS •
Vomiting
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Watery diarrhea
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Fever
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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.
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Encourage the guardian to give extra meal a day.
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Inform the guardian about the danger signs of diarrhea: • • •
Diarrhea with high fever Bloody diarrhea Diarrhea with increased vomiting
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Educate the guardian about the importance of good hygiene.
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Explain the importance of proper food handling.
PROGNOSIS EXCELLENT
