NURUL AIN BINTI ZAINAL ABIDIN

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PATIENT PROFILE:
Name: Ahmad Razali B Yusoff

Address: Bachang, Melaka

Age: 21 years old

Occupation: Student

Gender: Male

Date of clerking: 27th April 2016

CHIEF COMPLAINTS:
Loose stool and abdominal pain for 2 days
Fever and vomiting for 1 day
HISTORY OF PRESENTING ILLNESS:
Patient was apparently well until 2 days ago when he developed loose stools.
It was 2-3 episodes per day and watery in consistency. There was history of outside
food intake as he stayed in hostel Kolej Yayasan Melaka. However, there was no
change in colour of stools and no blood stained. It was non copious diarrhea.
Abdominal pain was for 2 days also. Pain was sudden in onset, intermittent, dull
aching with pain score of 4/10. No aggravating or relieving factor. No radiation of
pain and no relation with food. He developed low grade fever for 1 day. It was warm
to touch but no documented temperature.
Fever was not associated with chills and rigors. Tablet paracetamol taken and
fever subsided after that. He also had vomiting for 1 episode. Vomitus amount was
about half cup and contained food particles. It was preceded by nausea. No blood
stained and non bilious. Vomiting caused patient to have loss of appetite. None of
his friends are having the similar complaints as the patients.
For systemic review:
Constitutional symptoms - He has lethargy, but not claim of loss of weight
RS - no breathlessness, cough, runny nose
CVS - No palpitation, chest pain, orthopnea, paroxysmal nocturnal dysapnea
CNS - No headache, syncopal attack, fits, blurring of vision
Musculoskeletal - No muscle pain or joint pain
PAST HISTORY:
He has Bronchial Asthma for 7 years. Currently hes on MDI Salbutamol PRN
and well controlled. Last attack was 3 years ago. No history of Diabetes Mellitus,
hypertension or TB contact. No known drug allergy. No significant past surgical
history.
1

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FAMILY HISTORY:
He is the second out of 5 siblings. His mother has diabetes mellitus and on
medications. Otherwise, other family members are well and healthy. There is no
similar complaint among the family members. No history of malignancy in the
family
PERSONAL HISTORY:
His sleep pattern was disturbed due to the complaints. His bladder and bowel
habit is normal. Hes a non smoker, not consume alcohol and not an IV drug user.
SOCIAL HISTORY:
He stays in the hostel as he is a student of Kolej Yayasan Melaka, the hostel
is 5 minutes away from the KK. Hes financially supported by his parents.
SUMMARY:
21 years old Malay Male came with complaints of abdominal pain and loose
stool for 2 days, fever and vomiting for 1 day. The stool is watery in nature.
Abdominal pain is pointed around centre of abdomen. No similar symptoms
complained by his friends or family but there is history of eating outside food. He is
known case of bronchial asthma for 7 years and on medication.
GENERAL EXAMINATION:
Patient is alert and cooperative. He is moderately built and nourished,
sitting comfortably on chair. Body mass index is 21.3 kg/m 2 and there is no
abnormality over the skin.
There is no pallor over the nail and capillary refill time is less than 2 seconds.
The pulse rate is 90 beats/ minutes, regular rhythm, normal volume, no collapsing
pulse and no thickening of blood vessel. The respiratory rate is 18 breaths/minutes.
The blood pressure is 128/86 mmHg and temperature is 37 oC.
There is no pallor, jaundice, puffiness of eyelids or ptrygium. There is no
central cyanosis, sublingual icterus or tongue coating. Trachea is centrally placed,
no neck swelling and dilated vein. Jugular venous pressure is not raise and there are
no palpable cervical and axillary lymph nodes. There was no spine deformity nor
tenderness over the back. No spider naevi over the chest and back, no
gynaecomastia, no pedal edema and peripheral pulses were palpable.
SYSTEMIC EXAMINATION:

NURUL AIN BINTI ZAINAL ABIDIN

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DIFFERENTIAL DIAGNOSIS:
1.
2.
3.
4.

Acute gastroenteritis
Food poisoning
Appendicitis
Amoebiasis

PROVISIONAL DIAGNOSIS:
Acute gastroenteritis
INVESTIGATION
Investigation
Full blood count
Hb
Hematocrit
MCV
MCH
Platelet
TWBC
Stool culture

Findings/value
13.1 g/dL
38.5
85 f
28.6 pg
300 x 10^9/L
10.0 x10^9/L ()

Impression

Suggestive infection

MANAGEMENT:
1) Give medications for the symptoms :
- Tablet Lomotil QID
- ORS as needed
- Tablet Maxolon 10mg TDS
- Tablet Paracetamol 500mg QID
2) Advice the patient to :
- take plenty of water

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- have enough rest

- avoid outside food
- start with a light food like porridge or bread
DISCUSSION:
Acute gastroenteritis is a common cause of morbidity and mortality
worldwide. Conservative estimates put diarrhea in the top 5 causes of deaths
worldwide, with most occurring in young children in nonindustrialized countries. In
industrialized countries, diarrheal diseases are a significant cause for morbidity
across all age groups. Etiologies include bacteria, viruses, parasites, toxins, and
drugs. Viruses are responsible for a significant percentage of cases affecting
patients of all ages. Viral gastroenteritis ranges from a self-limited watery diarrheal
illness (usually < 1 wk) associated with symptoms of nausea, vomiting, anorexia,
malaise, or fever, to severe dehydration resulting in hospitalization or even death.
The clinician encounters acute viral gastroenteritis in 3 settings. The first is
sporadic gastroenteritis in infants, which most frequently is caused by rotavirus. The
second is epidemic gastroenteritis, which occurs either in semiclosed communities
(eg, families, institutions, ships, vacation spots) or as a result of classic food-borne
or water-borne pathogens. Most of these infections are caused by caliciviruses. The
third is sporadic acute gastroenteritis of adults, which most likely is caused by
caliciviruses, rotaviruses, astroviruses, or adenoviruses.
An index of suspicion can be generated for a specific set of potential causative
pathogens by considering the following stool characteristics:

Appearance
Volume
Frequency
Presence or absence of blood
pH
Presence or absence of reducing substances
White blood cell (WBC) count
Serum WBC count

Diarrhea is defined as daily stools with a mass greater than 15 g/kg for children
younger than 2 years and greater than 200 g for children 2 years or older. Adult
stool patterns vary from 1 stool every 3 days to 3 stools per day; therefore, consider
individual stool patterns.
Systemic features that can guide empiric therapy and help narrow the
differential diagnosis of the causative organism include the following:

NURUL AIN BINTI ZAINAL ABIDIN

Onset and duration of

symptoms
Presence or absence of
vomiting
Presence or absence of fever
Presence or absence of
abdominal pain

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Specific bacterial pathogens

may be associated with the
following:
Ingestion of particular foods
Exposure to water
Exposure to animals
Travel to particular countries
Preexisting conditions

Physical findings may include the following:

Dehydration (primary cause of morbidity and mortality)

Malnutrition (typically a sign of a chronic process)
Abdominal pain
Borborygmi
Perianal erythema

Diagnostic approaches may include the following assessments:

Stool pH
Presence of reducing substances in stool
Fecal leukocytes
Antilisteriolysin O (ALLO)
Identification of pseudomembranes in the colon by direct visualization
(diagnostic for C difficile)
Stool culture

A high index of suspicion is needed to choose the appropriate culture

medium. Media used to isolate bacteria responsible for gastroenteritis include the
following:

Blood agar: All aerobic bacteria and yeast; detects cytochrome oxidase
production
MacConkey EMB agar: Inhibits gram-positive organisms; permits lactose
fermentation
XLD agar and HE agar: Inhibit gram-positive organisms and nonpathogenic
gram-negative bacilli; permit lactose fermentation and H2S production
Skirrow agar: Selective for Campylobacter species
SM agar: Selective for enterohemorrhagic E coli
CIN agar: Selective for Yersinia enterocolitica
Thiosulfate-citrate-bile-sucrose (TCBS) agar: Selective for Vibrio species
CCFE agar: Selective for C difficile

Because most infectious diarrheas are self-limited, medical care is primarily

supportive and may include the following:

Oral rehydration: Live Lactobacillus GG and heat-killed Lactobacillus LB

reduce the duration of diarrhea in children when added to oral rehydration
solution [1, 2]
When oral rehydration is unsuccessful, intravenous (IV) rehydration
Close monitoring for secondary complications
For some bacterial gastroenteritis infections, antimicrobial therapy
For refractory cases of Cryptosporidium infection, antimotility agents

 Standard antimicrobial therapies for bacterial gastroenteritis include the

following:

Aeromonas species: Cefixime and most third- and fourth-generation

cephalosporins
Bacillus species: None necessary for self-limited gastroenteritis; vancomycin
and clindamycin for severe disease
Campylobacter species: Erythromycin; therapy started more than 4 days
after onset of symptoms appears to produce no clinical benefit
C difficile: Discontinuance of potential causative antibiotics; if this is
impossible or ineffective, oral metronidazole or (in seriously ill patients who
do not respond to metronidazole) vancomycin
Clostridium perfringens: None
Listeria species: None necessary unless invasive disease occurs; ampicillin
and trimethoprim-sulfamethoxazole (TMP-SMX) for invasive disease
Plesiomonas species: TMP-SMX or any cephalosporin
Vibrio cholerae: Tetracycline; in resistant cases, TMP-SMX, erythromycin,
doxycycline, chloramphenicol, or furazolidone
Yersinia species: TMP-SMX, fuoroquinolones, or aminoglycosides; reserved for
complicated cases
E coli: TMP-SMX if diarrhea is moderate or severe; for systemic complications,
a parenteral second-generation or third-generation cephalosporin
Salmonella species: None necessary for nontyphoid, uncomplicated diarrhea
but may be considered for infants younger than 3 months and for high-risk
patients (eg, those who are immunocompromised or have sickle cell disease);
for drug-sensitive strains, ampicillin or, alternatively, TMP-SMX,
fuoroquinolones, or third-generation cephalosporins
Shigella species: None necessary for most mild infections; for moderate-tosevere cases, ampicillin for drug-sensitive strains and TMP-SMX for ampicillinresistant strains or in cases of penicillin allergy; fuoroquinolones may be
considered in patients with highly resistant organisms

Dietary measures include the following:

Begin with the BRAT diet (ie, bananas, rice, applesauce, toast)
Introduce lean meats and clear fuids as soon as possible [3]
When giving lactose-containing dairy products, be alert for signs of
malabsorption
For infants, continue breastfeeding throughout the illness

REFERENCES:
1. Jennifer Lynn Bonheur, 2015, Bacterial gastroenteritis, Medscape retrieved
from http://emedicine.medscape.com/article/176400-overview

2. Michael Vincent F Tablang, 2014 , Viral gastroenteritis, Medscape retrieved

from http://emedicine.medscape.com/article/176515-overview