diarrhea of 1 day duration durante, esperon, espino, fernando, figuracion, flores, fong, francisco j
TRANSCRIPT
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DIARRHEA OF 1 DAY DURATION
Durante, Esperon, Espino, Fernando, Figuracion, Flores, Fong, Francisco
J.
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Identifying Data
5 month old Male Admitted for the first time
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Chief Complaint
Diarrhea of 1 day duration
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History of Present Illness
Diarrhea watery in consistency, yellow and color and non-foul smelling
It is non-bloody and non-mucoid Episodes of diarrhea was approximated to be at least one episode in ten minutes
associated with irritability & decreased in activity
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History of Present Illness
sunken eyeballs depressed anterior fontanelle and increased water hunger patient had an undocumented fever few hours PTA
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History of Present Illness
no vomiting and skin changes Urine output and last urine output cannot be ascertained
The patient was not introduced to a new diet.
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Prenatal History
The mother had hyperglycemia at 6 months
She had UTI at first trimester and was prescribed with Cefalexin for 1 week
She had cough and cold at first trimester and was prescribed with unrecalled antibiotic
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Birth History
born full-term via normal spontaneous vaginal delivery at a hospital, physician-assisted
Birth weight = 2360g Birth Length = 46cm had a lump on his head that was non-progressive and went away before 1 month of age
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Neonatal History
had cough and cold that presented as runny nose
prescribed with carbocysteine and an unrecalled medication
Medication were taken with good compliance
no history of jaundice, pallor, convulsions, hemorrhage or dyspnea
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Feeding History
The patient was not breastfed. No history of milk allergy No solid food was given to the patient
From birth to 2 months S26 with a dilution of 2:1given every 3 hours.
From 2 months to present BONA with a dilution of 2:1given every 5 hours
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Immunization History
BCG vaccine at 1 month of age 3 doses of DPT at 3 months, 4 months, and 5 months of age
3 doses of OPV at 3, 4, 5 months of age
2 doses of Hepatitis B vaccine at birth and 3 months of age and
Measles vaccine
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Developmental History
1 month: responds to sounds; stares at faces
2 months: vocalizes; follows objects 3 months: laughs; holds head up steadily; squeals, coos, recognizes voice
4 months: can grasp toys; roll over; can bear weight on legs
5 months: recognizes own name; turns towards sounds; play with hands and feet
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Past Health History
no prior history of illness
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Social and Environmental History lives in an apartment with 2 bedrooms and 1 toilet and bath together with 3 other occupants
garbage is collected every day Water for utility purposes is from Maynilad and drinking water form from a distilling station
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Physical Examination
Vital Signs Pulse: 140 bpm Respiratory Rate: 35 breaths/min Temperature: 36.9° C axillary
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Physical Examination
Anthropometric Measurements Height/Length: Weight: Head Circumference: Chest Circumference: Abdominal Circumference: Wasting: Stunting:
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Physical Examination
Skin No lesions were noted Smooth and warm has normal turgor
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Physical Examination
HEENT anterior fontanel open and not depressed; posterior closed; symmetric
anicteric sclerae, pinkish palpebral conjunctivae, eyeballs are not sunken
oral mucosa is pink, moist and smooth all lymph nodes are normal and nontender.
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Physical Examination
Chest Good and equal chest expansion. Audible breath sounds. No rhonchi, rales or wheezes noted
Cardiovascular adynamic precordium good and distinct S1 and S2, no murmurs or extra heart sounds
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Physical Examination
Abdomen Abdomen was protuberant but soft normoactive bowel sounds all 4 quadrants are tympanitic no tenderness and mass noted on light and deep palpation
liver edge is 1cm below the right costal margin
spleen and kidneys palpable.
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Physical Examination
Genitalia Tanner stage 1 Normal scrotum on both sides, testes descended.
Musculoskeletal no deformities Negative Ortolani and Barlow tests
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Neurologic Examination
Mental status the patient is awake, has regard to people around him and responsive to any kind of stimuli
Motor tone no flaccidity and/or spasticity
Sensory function positive withdrawal to painful stimuli
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Neurologic Examination
Cranial nerves I – cannot be assessed II - acknowledged presence with facial expression and tracking
II, III - (+) optic blink reflex, (+) papillary response
III, IV, VI - (+) tracking, all directions V - effectively sucks milk from bottle VIII - simultaneous blink upon hearing loud clap
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Neurologic Examination
IX and X - good coordination during swallowing and sucking
XI - symmetrical shoulders XII - tongue midline
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Neurologic Examination
Deep tendon reflexes +2 on ankle, knee and elbow
Primitive Reflexes Negative: Moro reflex, rooting reflex
Positive: support reflex, placing/stepping reflex, Parachute reflex, Palmar grasp, Plantar grasp, Babinski
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Subjective
5-month old diarrhea of 1 day duration
yellow in color, non- foul smelling, non-bloody and non-mucoid
irritability, decrease in activity, sunken eyeballs; depressed anterior fontanelle; increased water hunger. the urine in the diaper.
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Subjective
had undocumented fever the next day
no vomiting and no new food introduced
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Objective
Unremarkable PE PE done on the 4th hospital day
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Primary Impression:ETEC Diarrhea PRIMARILY CONSIDERED DUE TO:
age of incidence symptoms the patient manifested
watery diarrhea and fever
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Primary Impression:ETEC Diarrhea
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Differential Diagnosis:Typhoid Fever
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Differential Diagnosis:Giardiasis
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Differential Diagnosis:Rotavirus Gastroenteritis
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Differential Diagnosis:Vibrio Cholera Gastroenteritis
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Plan
Assessment of the fluid status
Symptom Mild to moderate (3-9% loss of body wt)
Mental status Normal, fatigued or restless; irritable
Thirst Thirsty; eager to drink
Eyes Slightly sunken
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Plan
Give ORS; 75 cc/kg in 4 hours If at the 4th hour, the patient is well discontinue ORS and give sugar/salt solution 50-100 cc for every bowel movement
If however the patient deteriorates proceed with intravenous therapy, 75 cc/kg in 4 hours LRS (lactated ringer solution)
If reassessment shows severe dehydration (>10% weight loss) we should give 30 cc/kg in 1 hour and 70 cc/kg in the next 5 hours
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Plan
If ETEC is suspected bacterial culture should be done from samples of stool
Antibiotics can shorten the duration but usually not required Fluoroquinolones have been shown to be effective therapy