Sie sind auf Seite 1von 13


PAC 6016







Name : Muhammad Nur Israf

Age : 3 years old 2 month
Sex : Male
Race : Malay
Address : Temerloh
Date of admission : 26/ 11 / 2014
Date of clercking : 30 / 11 / 2014
Informer : Mother


Patient came to Hospital Temerloh due to vomiting and diarrhea four days prior to


He was apparently well until he had vomiting and diarrhea on 22 nd November

2014. On that day, he had vomiting more than 3 times per day. Regarding the vomitus, it
was non projectile and mainly food particles with lots of amount. However, there was no
blood stain. Regarding the diarrhea, it was yellow green with mucus, odourless and no
blood stains. The diarrhea occur more than 3 times per day. It was associated with
fever. Regarding the fever, there was chill, however no myalgia, arthralgia,retroorbital
pain and rashes. No documentated temperature at that time. As the result, she was

brought to Hospital Jerantut. In emergency department, his temperature was 39 C , he

was released back home after the fever went down and accompanied with ORS and

On the next few day, the symptoms still present but there was improvement.
However, he started to complain abdominal pain and relieved when defecate. There
was no fever. At that time, he started to have fatigue and not active.
On 26th November 2014, he had vomiting ten times with minimal amount. The
contents was only fluid and no blood stain. The diarrhea still persist but not severe as
before with same presentation as before. As the result he was brought to Hospital
Jerantut, in emergency department he was given oral rehydration salt and transfer to
Hospital Temerloh for further management.

Since admission, he was treated with ORS and several type of antibiotic.
According to his mother, there were changes of antibiotic due to the aggravated of
vomiting in 1st introduction and the 2nd and 3rd times the fever still persist. Since the 4th
antibiotic was given, the child respond well with it as evidence of no fever and no

Otherwise, there was no history of outside food, no history of travelling, no family

member has similar symptoms and there was no urinary tract infection.


Central nervous system

- no loss of conciousness
- no headache
- no visual disturbances

Cardiovascular system
- no palpitation
- no chest pain

Respiratory system
- no shortness of breath
- no cough

Genitourinary system
-no dysuria
-no oliguria

This is his first hospitalization, otherwise there is no other admission and he

never undergone any operation.


Antenatal history

Mother did not developed any illnesses during antenatal period such as fever,
rash, gestational diabetes mellitus and hypertension.

Birth history

He was born in term via spontaneous vagina delivery with a birth weight of 3.1
Kg. There was no complication during birth and after birth


His immunization is up to age.


Gross motor : he can skip on both feet, running, kicking and climbing
Fine motor : he was able to draw straight line, circle and cross line
without seeing how it is done. He can draw recognisable
such as cartoon and and ice-cream.
Speech and language :He knows his age, names 3 colours, he can talk constantly
in 4-5 words and understand command.

Social : Able to dress himself with the help of mother, able to button
and unbutton himself


He is the youngest child out of four siblings. The eldest is 18 years old female, the
second is 16 years old female , the third is 12 years old boy. His father was
hypertension since 12 years ago and on medication.


He lives with her parents at Jerantut. Currently, he is taken care by her mother at
home. Usually, he will have his meal at home prepared by his mother. The mother
describe him as active and playful boy. The father was disable person since 12 years
ago, worked as rubber tapper and non-alcohol consumer and also non-smoker. The
family income for monthly was RM800.


He not allergic to any food and eat normal adult diet.




A 3 years 2 month old malay boy presented to Hospital Temerloh with vomiting and
diarrhea 4 days prior to admission. There was history of abdominal pain and tenesmus.
However, there was no history of taking outside food




Patient was lying supine comfortably. His behavior was appropriate for his age
and he was not irritable. He was alert, in tachypnea and looked restless. There was a
cannula attached to his left arm connected to IV normal saline.

Vital sign

Blood pressure : 98/58 mmHg

Respiratory rate : 32 per minute
Pulse rate : 108 beats /min
Temperature : 37 oC

Anthropometric measurement
Height : 96 cm
Weight : 11.3 kg

As the result , the height centile is within 25-50 centile and for the weight is below 3 rd


The hand was warm, dry and soft

Palmar crease was not pale
No cyanosis
Capillary filling was good
The skin tugor was normal


There was no ear nose and throat discharge

There were sunken eyes seen on his face
Eye : No pallor and jaundice
Mouth : The tongue is dry and there is no central cyanosis

There was no pitting edema


Abdominal Examination

On inspection

The abdomen was not distended, move with respiration, the umbilical was
centrally located, no surgical scars and visible vein noted

On palpation

Light palpation revealed soft abdomen , no guarding and ,non-tender

Deep palpation revealed no signs of hepatosplenomegaly, kidneys were
unballotable and negative shifting dullness

On Auscultation
The bowel sound was normal and no renal bruit

Cardiovascular examination

On Inspection
The chest move with respiration. There was no scar and dilated vein.

On Palpation
Apex beat is at left fifth intercostal space at midclavicular line, jugular venous
pressure was not raised, there was no parasternal heave and no palpable thrill

On Auscultation
First heart sound and second heart sound was heard and there was no added
sound heard

Respiratory examination


On inspection, the chest is move symmetrically with respiration, there is no scar

and dilated vein

On Palpation

Apex beat : left 5th intercostals space at midclavicular line, trachea is centrally
located, chest expansion was normal and vocal fremitus was normal.

On Percussion

Resonance of all lobe

On Auscultation

There was no ronchi and crepitation

Central nervous system examination

On inspection, there was no abnormal movement seen

All cranial nerves were intact
Tone, power, and reflexes for both upper and lower limbs were normal


Acute Gastroenteritis with mild dehydration.

Based from the history of the symptoms of generalized colicky abdominal pain
associated with several episodes of diarrhea and vomiting is the typical features for
Acute gastroenteritis. On systemic review, this patient has no other problems that can
excude the AGE. Regarding the clinical findings, generally revealed signs that indicate
dehydration, otherwise the other systems were all in normal limit. Therefore, this is most
likely diagnosis.

1.Acute appendicitis
Point for : vomitting and abdominal pain
Point against : usually not assocated with diarrhea
2. Small bowel obstruction :
Point for : vomiting and diarrhea
Point against : the vomitus was not bile-stained, the abdominal pain was not
Severe and not blood stained.
3,Dengue Fever
Point for : has fever, abdominal pain and fatigue
Point against : no rashes, no myalgia, no retro-orbital pain, no athralgia


For the investigations, I would like to do:

1. Full blood count

Reason: To look for and evidence of infection either bacterial or viral

Result :

WBC : 15.8 x109/L

RBC : 3.95 x 1012/L
Hb : 12.2 g/dL
Hct : 37.8 %
Plt : 432 x 109/L
Lymphocyte : 8.5 x 109/L
Interpretation: From the result we see that the patient have lymphocytosis that
indicated viral infection. The patient Hct also less than normal limit
maybe due to dehydration

2. Blood urea and serum electrolytes

Reason: To look for imbalance in serum electrolyte due to several

episodes of vomiting and diarrhea

Result :

Sodium : 140 mmol/L

Potassium : 3.2 mmol/L
Urea : 3.7 mmol/L

Interpretation: The electrolytes in this patient is in normal limit. There was a

decrease in potassium level that may indicate hypokalaemia due
to episodes of vomiting.

3. Stool culture and sensitivity

Reason: To provide a further plan of management

Result :-

4.Stool FEME

Reason: To look for any occult blood loss and look for organism involved
Result : Negative

5.Renal function test:

Reason: To look abnormalities in renal function (urea and creatinine). In Acute

Gastroenteritis, the hypovolemic condition can cause Acute kidney
Result :

Creatinine : 85 mmol/L
Uric acid : 395 mmol/L

Interpretation: It has normal ratio of urea and creatinine, so there was no acute
kidney injury.

The principle management of acute gastroenteritis is about to correct the fluid
and electrolytes imbalance. This is because the patient have loss of fluid and
electrolytes due to diarrhea and vomiting. In severe case, it may lead to metabolic
acidosis due to severe dehydration.

First of all, we must monitor vital signs such as blood pressure, respiratory rate
and heart rate. In addition, we must monitor input and output chart. These steps should
be done to prevent hypovolemic shock.

For dehydration, different class classification have different management. Initially,

we must classified the class of dehydration base on clinical examination.
There are 3 class of them such as mild, moderate and severe. There are certain criteria
which class the patient is in.

Features Mild Moderate Severe Patient

Body <5% 5-10 % >10 % None
weight loss
General Thirst Thirsty/restless/lethargi Drowsy/cold/sweatin Thirst
apperance c g
Tears Present Reduce/absent absent Presen
Skin tugor Normal Reduce/Normal Prolonged Normal
Mucous Dry Dry Very dry Dry
Cap refill Normal Normal/prolonged Prolonged(>2 sec) Normal
BP Normal Normal/low Very low Normal
Urine reduce Reduce Marked oliguria Normal
Pulse rate normal Rapid Rapid and weak Rapid
Eyes Normal/Sunke Sunken Grossly sunken Sunken
Anterior Flat Sunken Very sunken flat

In this case, the patient was put under mild dehydration. For mild dehydration, we
should manage him by giving a trial of oral rehydration solution (ORS) 40-60 mL/Kg
within 4-6 hours, then replace with 10 mL/kg of ORS every diarrhea episode. He must
be feed normally.

We started the antibiotic once we got the result of blood cultures and sensitivity
that revealed what types of organism it was. The common antibiotics used are
tetracycline and erythromycin.

Finally, we should consider to discharge her if he have fulfilled the following

criteria such as disappearance of fever, passage of fewer stool, improved appetite and
return to normal activity.


Acute gastroenteritis accounts for millions of deaths each year in young children,
mostly in developing communities. In developed countries it is a common reason for
presentation to general practice or emergency departments and for admission to
hospital. Dehydration, which may be associated with electrolyte disturbance and
metabolic acidosis, is the most frequent and dangerous complication.

Acute gastroenteritis presented with diarrhea or vomiting and can be both of

symptoms more than seven days duration. It may be accompanied by fever, abdominal
pain, and anorexia. Diarrhea is the passage of excessively liquid or frequent stools with
increased water content.
The causes of acute gastroenteritis in children mainly because of viral infection.
The most common viral affected children is rotavirus. The protozoa such as Giardia
lambai and Entamoeba histolytica can cause acute gastro enteritis. In fact, the bacteria
cause acute gastro enteritis, for example Campylobacter jejuni, Enteropathogenic,
Escherichia coli , Non-typhoid, Salmonella spp and Shigella spp

Diagnosis can be made clinically. Information should be sought about recent

contact with people with gastroenteritis, nature and frequency of stool and vomitus, fluid
intake and urine output, travel, and use of antibiotics and other drugs that may cause
diarrhea. Chronic constipation is common in children, and fecal overflow incontinence
may present as spurious diarrhea . Diarrhea and vomiting are non-specific symptoms in
young children, and the diagnosis of gastroenteritis should be questioned in children
with high fever, prolonged symptoms, or signs suggesting a surgical cause (such as
severe abdominal pain, bilious vomiting, abdominal mass).

The are many complications of acute gastroenteritis such as dehydration,

metabolic acidosis and electrolytes disturbances like hypernatremia, hyponatremia and
hypokalaemia. In addition, it may also cause hemolytic uremic syndrome.

The patient better to be treated in the ward. There are few indication of
admission such as need for intravenous therapy, uncertain of diagnosis so the work up
are needed to find the causes, patient factors for example patient is too young and
worsening of symptoms, caregiver unable to give full commitment to take care of the
children and social and logistic factor such as too far away from hospital and hard to
return back if something bad happen such as worsening of vomiting and diarrhea.

Dehydration is occuring when water intake is insufficient to replace free water

lost due to normal physiologic processes for example breathing or urination and other
causes such as diarrhea or vomiting. The type of dehydration should be determined.
There are three type of dehydration, hyponatremic, isonatremic and hypernatremic. The
hyponatremic dehydration meant that the sodium loss more than water loss. It due to
shift of water into intracellular compartment and this can finally cause convulsion. The
isonatremic dehydration is sodium loss equal or approximately equal to water loss. The
hypernatremic dehydration is water loss more than sodium loss. It due to water shift to
extracellular compartment. Clinically, this condition hard to recognize early and can
cause multiple and small cerebral hemorrhage.


1. Paediatric Notes