CBD dehydrated child case presenttation- case.pptx

cbd dehyrated child

1. CBD Approach to dehydrated child

2. 1. PATIENT IDENTIFICATION DATA Name: D Age: 4 years old Gender: Male Race: Malay Date of admission: 14/10/2022 Date of clerking: 16/10/2022 Informant: mother

3. Chief complain He presented with diarrhea and vomiting 2 days prior to admission

4. HOPI 2 days PTA ( 12/10/22) 9am - He developed diarrhea & vomiting Diarrhea Onset : sudden onset Consistensy : Watery Severity : moderate to large amount , for more than 10 times within 12 hours No foul smelling , no blood & mucus stained Vomiting Onset : Shortly after the onset of diarrhea Characteristic : vomitus was non- billous and did not contain blood , non-projectile Severity : Immediately after each feeding , for more than 5 times within 12 hours

5. On the same day , 12/10/22 7pm went to clinic and discharged with ORS. 13/10/22 (1PTA) 5pm Vomiting and diarrhea is still persistent , do not become better Patient become less active and have poor feeding Patient developed sudden onset low grade fever , not associated with chills and rigors and relieved by paracetamol.

6. 14/10/2022 8am (on the day of admission) Mother noticed patient look very lethargy and irritable with pale and cold skin and developed sunken eyes This is worrying her and went to ED Fluid resuscitation and IV normal saline was given to him immeadiately as patient have signs for shock. After vital signs is stable , he is admitted to ward.

7. No abdominal discomfort No ill contact , history of taking food outside , no similar event in his family No history of upper respiratory tract infection in the past few weeks No recent travel and no recent exposure to animal

8. Systemic review CVS Cold and clammy skin , no cyanosis , no bluish discolouration Respi No cough , no difficulty in breathing GUT Normal urine output, no hematuria , normal colour urine MSK No joint swelling , no joint pain ENT No ear or nasal discharge , no feeding difficulty, no runny nose Hemato No gum bleeding or epistaxis

9. Antenatal history - His mother pregnant on her at the age of 30 years old - Attended all rountine ANC and had no obstetric problems Birth history -born full term via SVD , birth weight 2.7kg and cried right after birth Postnatal - He did not developed any problems postnatally.

10. Developmental history Developmental milestones is corresponding to his chronological age. Gross motor : walks or runs up and down stairs one foot per step Vision& fine motor : can draws a person with head, legs and trunks. Speech & language : can speech grammatically correct and completely intelligible Personal & social : brushes teeth himself

11. Immunisation history Immunisation was up to date Nutritional history He is now on food supplementary - How to ask? Related to diarrhea?

12. Past medical history This is his first admission to hospital Past surgical history He did not undergone any operation before Drug history & Allergy history He is not on any regular prescribed medication He is not known of any allergy to food and medication

13. Family history He is the youngest out of 3 siblings All his siblings are fit and healthy His parents were well and there is no history of allergy , chronic illness or any maglinancy run in his family. No family history of lactose intolerance and IBD

14. PHYSICAL EXAMINATION GENERAL INSPECTION He is a young boy with thin - built body size , lying supine in flat position. He was alert and conscious and responsive. He was not tachypneic, not in respiratory distress and not in pain. His nutritional and hydrational status were adequate (patient no longer had dry lips and sunken eyes) There was no dysmorphism and abnormal movement. There is a branula attached to his dorsum of right hand.

15. GENERAL EXAMINATION Hand: warm, dry and pink. Capillary refilling time is less than 2 seconds. Radial pulse palpable, good volume regular rhythm. Eyes: no jaundice , conjunctiva is pink. No sunken eyes noted. Mouth: lips is moist. Tongue is moist. Oral hygiene is good. Neck: no neck swelling or palpable lymph node. Leg: warm peripheries and peripheral pulses are palpable.

16. ANTHROPOMETRIC MEASUREMENT Height : 98 cm (between 5 th and 10 th centile) Weight : 15 kg (between 5 th and 10 th centile)

17. VITAL SIGNS Pulse rate : 102 bpm, good volume, regular rhythm (normal) Respiratory rate : 28 breaths/min (normal) Temperature : 37°C (afebrile) Blood pressure : 107/64 mmhg (normal) *all normal

18. ABDOMINAL EXAMINATION Inspection Abdomen is not distended and moves symmetrically with respiration. Umbilicus is centrally located and inverted. There are no skin discoloration, surgical scars, dilated veins or visible peristalsis seen. Palpation On superficial palpation, abdomen is soft and non-tender and no guarding. On deep palpation, abdomen is non-tender and no mass palpable. Liver and spleen are not palpable and both kidneys are not ballotable. Percussion The abdomen was resonance and there was no shifting dullness. Auscultation Bowel sound was present with normal intensity. There was no audible sounds such as renal bruits.

19. CARDIOVASCULAR EXAMINATION Inspection Chest have no deformity. Chest moves with each respiration bilaterally symmetrical. There is no visible pulsation, no surgical scar seen and no dilated vein. Palpation Apex beat is palpable at 4 th intercostal space, line with mid-clavicular line. There is no thrill and no parasternal heave. Auscultation Normal 1 st and 2 nd heart sound was heard.no murmurs heard.

20. RESPIRATORY EXAMINATION Inspection Chest have no deformity. Chest moves with each respiration bilaterally symmetrical. There is no visible pulsation, no surgical scar seen and no dilated vein. Palpation Chest expansion is normal. Percussion Normal chest resonance. Auscultati o n Air entry is equal bilaterally with normal vesicular breath sound. No added sound.

21. SUMMARY In summary, my patient, 4 years old Malay boy presented with high-grade fever 2 days PTA, diarrhea and vomiting 1 day PTA associated with lethargy, loss of weight and signs of dehydration (dry lips, sunken eyes. Patient developed poor oral intake and became less active. On physical examination, there was unremarkable findings.

22. PROVISIONAL DIAGNOSIS Acute gastroenteritis with 10% dehydration Points for Points against Vomiting Diarrhea Fever Signs of dehydration (dry lips, sunken eyes,lethargy ) Loss of weight no abdominal pain

23. 2. Urinary tract infection Points for Points against Fever Vomiting Poor oral intake lethargic diarrhea no dysuria, normal urine ouput

24. 3. Intussusception Points for Points against vomiting diarrhea the vomitous was not bile-stained no abdominal pain no blood-stained stool

25. Investigations (1.Full blood count) Component Result Status Range Units WBC 14.2 5.0-15.0 x 10 9 / L NEUT 82.2 HIGH 40.0-80.0 % LYMPH 9.9 LOW 20.0-40.0 % EOSI 0.00 LOW 1.00-6.00 % MONO 7.90 2.00-10.00 % BASO 0. 100 LOW 0.500-2.000 % RBC 8.03 HIGH 3.90-5.10 x 10 12 / L HGB 118.0 111.0-141.0 g/L MCV 54.3 LOW 72.0-84.0 fL MCH 14.9 LOW 25.0-29.0 pg MCHC 275.0 LOW 320.0-360.0 g/L RDW 23.7 HIGH 11.6-14.8 %CV PLT 891 HIGH 200-550 x 10 9 / L

26. 2. BUSEC RESULT UNIT REF. RANGE UREA 8.0 mmol/L 2.8-7.2 SODIUM 134 mmol/L 129-143 POTASSIUM 3.9 mmol/L 3.5-5.1 CHLORIDE 104 mmol/L 93-112

27. Treatment At ED Fluid resuscitation 7.35am – IVD NS 150cc bolus (10cc/kg) 7.40am – IVD NSD5 52cc/hour ( maintainance ) 7.50am- IVD NS 150cc bolus (10cc/kg) 8.30am- IVD NS 63cc/hour (correction) 8.45am- IVD NSD5 52cc/hour 9.30 am- IVD NS 63cc/ hour 9.45 am- IVD NSD5 52cc/hour Vital sign monitoring

28. In ward strict input/output charting IVD NSd5% full maintainance 52cc IVD 10% correction 32CC NS ORS 10mls/kg/purge IV Cefriaxone 750mg