DEMOGRAPHY

Name: Thivagaran A/L Muthiah

Age: 5 years 5 months old
Gender: Male
Race: indian
Address: ayer tawar
Date of admission: 2/12/2018
Date of clerking: 6/12/2018
Date of discharge: 4/12/2018

*Informant : patients’ mother

Chief complaint

Presented with vomitting , diarrhea and fever 1 day prior to admission.

History presenting illness

He was apparently well until two days prior to admission his parents noticed that he started
vomitting and having diarrhea in the morning as well in the afternnoon and evening at home.
The fever was of sudden onset and continuous throughout the day and detected by his mother
during afternoon time ,and it was not associated with chill and rigors. It is relieved temporarily
by Paracetamol given by the Klinik Kesihatan 1Malaysia . Patient vomitted around 15 times in
a day , the vomitus content was food particle( rice mainly.)The volume was about 2 tablespoon
, there was no foul smelling and blood stained .The vomitting was aggravated after drinking
water or eating any food for the day. Due to the vommiting ,patient appettite was decreased and
had poor oral intake for the whole day. Patient has diarrhea for 7 times in a day, the stool was
watery in consistency and yellowish colour. .There was no blood stained in the stool.The
diarhea was exagerated by the vomititng.The vommiting occurs before having diarrhea.
Patient also has colicy in nature type of abdominal pain mainly at the right quadrant, the
abdominal pain exerbated by each time diarrhea. Before this patient was very active till the day
, but now he is seen tired and less active. .
According to the parents patient did not ate any food in the school that morning. The night
before patient has laksa r wherea s smother had satay in restaurant at roadside. Opon further
questioning , There is none of patient family members having vomiting or diarrhea .There is no
water related activities such as swimming attended by the patient. Patient is also staying is a
dengue prone are where fogging in done many times. Patient had normal microturition, there
was no dysuria or foul smelling urine or blood stained urine.

Systemic review:
Cardiovascular system: No cyanosis , no palpitaion noted
Respiratory system: No shortness of breath, no cough , no flu.
Genitourinary No UTI symptoms
Other system history was unremarkable.

Past medical history :

There is no significant history noted

Past surgical history:

There is no significant history noted.
Drug or allergic history:
There is no known allergic to drug or food.

Paediatric history
Prenatal history
The mother was 30 years old when she delivered him. This is her Second pregnancy. She
attended all the antenatal check-up along the period of pregnancy. According to her, she was
healthy not has complication like pregnancy-induced hypertension, gestational diabetes
mellitus or preeclampsia along the period of pregnancy. She did not smoke or consume alcohol
during the pregnancy.

Birth history
Thivagaran was born in term through spontaneous vaginal delivery in Hospital Taiping
without any complication and no instrumental intervention done . His birth weight was 3.2kg.

Neonatal history
Thivagaran has neonatal jaundice which resolves itself and did not need any hospital
admission, he had no breathing problems and no any congenital abnormality detected.

Feeding and nutritional history

He was breastfed since birth until the age of 6 months of age. Then he was given with
formulated milk since 3 months old . He started to take family dietary such as meat, vegetable,
rice and porridge since 1 year old.

Immunisation history
The vaccination was up to date.

Developmental milestones
He is a school going boy, he is doing well with his academic performances and also active
in sports. He has also may friends in kindergarden .He is able to read and write in sentences.
Conclusion: his developmental is up to age

Family history:
His father is 40 years old lorry driver alive and well , mother is 37 years old factory worker
alive and well. He is the only child .
There is no significant disease like diabetes mellitus, hypertension and astma in the family.

Social History
Thivagaran and his parents live in a teres house with basic amenities. There is no factory near
their house and no known neighbours have respiratory infection.His father smokes at home
everyday and consumes alcohol on accasion. Thus, making thivagaran is a passive smoker..

Effect of illnes towards his parents:

Mother was very tired and busy as she had take holiday to take care of Thivagar.

General examination:
On general inspection, a medium body built boy was lying comfortable and and cooperative
during the examination. He is having iv branula on left dorsum of hand and an identity tag on
the right wrist. He looked pink and well nourish. He was alert, conscious and well orientated. .
There was no respiratory distress, dysmorphic feature and. Although hydration status was fair ,
patient was thirsty as he was gulping down water from the cup very fast.

Anthropometrics measurement:
Height :
Weight : attached (last page)
vital Signs:
Temperature : 37.5°C
Pulse Rate : 96 beats/ minute, regular rhythm, normal volume
Respiratory Rate : 25breaths/ minute - patient is not having tacypnea
Blood pressure : 90/70 mmhg - normal for 50 th centile for age
Oxygen saturation : 95%

Hand
The nail bed was pink. There was palmar pallor , no clubbing, splinter haemorrhage,
palmar erythema, leukonychia or koilonychias. Radial pulse was regular rhythm and normal
volume. Capillary refilling time was less than 2 seconds which is normal. No skin rash and sign
of skin infection such as impetigo.

Head
Eyes : No jaundice, no pallor of conjunctivae and there is sunken eyes upon
examination
Mouth : No central cyanosis or pallor. The lips was dry and he had fair oral hygiene. There
was no glosiitis or angular stomatitis noted.
Ear : No discharge noted
Neck : No palpable lymph nodes.
Legs : No clubbing, cyanosis and pitting ankle edema.

Physical examination of abdomen:

Abdominal examination
On inspection, the abdomen was flat and it move with respiration. There is no dilated
vein, visible peristalsis, scar and visible mass. The umbilicus was inverted and centrally
located.
Upon palpation, the there is skin tugor as the skin goes back slowly revealing signs of
dehydration .The abdomen was soft, non-tender, no palpable mass in light and deep palpation.
The liver, spleen and kidney are not palpable. There is no shifting dullness and the bowel sound
was present.

Respiratory system
On inspection, the chest moved symmetrically with respiration. There was no subcostal
recession, intercostals and suprastenal recession noted. There was no chest deformity, no
dilated vein and no scar noted.
 Chest expansion and tactile vocal fremitus cannot be assessed as the patient was not
cooperative. There was no displacement of apex beat.
On percussion, both lung fields were resonance with normal liver and cardiac dullness.
Upon auscultation , there was bilateral equal air entry.There was normal vesicular
breath sound .

* Other system examination was not remarkable.

Summary:
Thivagaran a 7 years old school going indian boy has been admitted due to having vomiiting,
diarhea and fever 1 day prior to admisiion ,he had eaten roadside restaurant food 1 day before
symptoms started and stays at a dengue prone area. Upon Physical examination his lips was
dry and abdomen skin tugor was abnormal revealing dehydration.

Provisional diagnosis:
Acute gastroenteritis
- patient is only 7 years old school going boy
- patient has vomitting, diarrhea (watery stool ) and fever,
- patient consumes roadside food before the illness started
- patient had dehydration signs and symptom

Differential diagnosis:

1.Dengue fever
Point for: points against:
- stays at dengue prone area - continous fever wihout chils and rigor
- had fever - ns1 antigen was negative
- hematocrit level not increase, -
-platelet level not decrased
- had vomiitng , diarrhea , abdominal pain
2. Food poisoning
-patient has vomitting, diarrhea (watery stool ) and fever,
- patient consumes roadside food before the illness started
- patient had dehydration signs and symptom

Investigations
The following were investigations done in the ward:
1. Full blood count
Reason: to detect any sign of inflammation.

Hemoglobin (10.5-14.0 g/dl) 13

Packed cell volume (33-42%) 35

Mean corpuscular volume (70-74fL) 72

Mean corpuscular hemoglobin (25-31pg) 25

Total white blood cell (6-15X1000 per c mm) 15500

Neutrophil (30-50%) 30

Eosinophil (1-6%) 0

Basophil (0-1%) 0

Lymphocyte (20-45%) 25

Monocyte (0-1%) 0

Platelet (150,000- 400,000cmm³) 320,000

Interpretation: the total white blood cells increased indicating infection.

2. Blood urea and serum electrolytes (BUSE)

Reason: to detect any electrolyte imbalances showing dehydration..
Result:

Sodium (137- 146mmol/L) 139

Potassium (3.8-5.2mmol/L) 4.1

Chloride (97-107mmol/L) 105

 Blood urea (1.7-8.3mmol/L) 3.3

Interpretation: There is no presence of hypokalemia. And hyponatremia. All other

components are in normal range.

3. . Urine Full examination and microscopic examination

Biochemistry
PH 6.0

Protein negative

glucose negative

ketone negative

Blood heam and myoglobulin negative

Nitrate negative

Interpretation= No urinary tract infection.

4 . NS1 antigen- negative.

There is no dengue infection.

Final diagnosis: acute gastroenteritis.

Treatment –
1. Monitor the vital sign, set on iv line to treat the dehydration and oral rehydration salt
can be given according to dosage.
2. Look the pattern of the fever
4. Encourage orally intake such as bland and non- spicy food..
5. Give paracetamol syrup to control the fever
6 If there is still vomitting medication is given , diarrhea is controlled as well using(
stool chart)
7. Give educational to the mother on hygiene of food is important in children as they
are very fast susceptible to viral infection.
Discussion:

These days acute gastroenteritis is very vunerable among school going children . The most
common cause is the rota virus .Rotavirus is the leading cause of severe gastroenteritis in
the pediatric population worldwide . These infections mainly occur in children between
6 and 24 months of age

Annually about two billion cases of diarrheal diseases occur among children under the
age of five globally . Despite the fact that acute gastroenteritis can be prevented the
disease still affects children, particularly under the age of two . Gastroenteritis results
from an inflammation of the gastrointestinal tract commonly caused by viral
pathogens and less frequently by bacterial or parasitic organisms . Every year about
1.5 million children die from diarrheal diseases, mostly in developing countries; this
makes diarrheal diseases the second most common cause of death among children
under the age of five following pneumonia .
Although the burden of diarrheal diseases among children under the age of five is
heavy, improved prevention is achievable. Personal and food hygiene, including the
use of clean water sources, are key measures to prevent transmission of these
diseases . Breastfeeding, especially under 6 months of age, also effectively protects
infants . **Rotavirus vaccination has been widely available for children since 2006
and is now recommended worldwide . A growing body of evidence now supports the
benefits of this vaccination and its universal implementation, both in the developed
and developing world .
Treatment can also be improved, in part through better adherence to recent guidelines .
The most important complication of gastroenteritis and the leading cause of death is
dehydration; the mainstay treatment for gastroenteritis is oral rehydration . Antiemetics
are another treatment option that, despite sporadic use as adjuvant therapy, is not
formally recommended in any international guidelines . For my patient , the appropite
treatment was given such as monitoring the hydration status and makingsure the patient
does no go into shock. .