Biodata

Name: Sharvin S/O Panmiselvam

Age: 1 year month
Date of Birth: 31st / August/ 2011
Gender: Male
Race: Indian
Address: Ladang Tuan, Karak
Source of History: Mother
Date of Admission: 24th / September / 2012
Date of Clerking: 25th / September / 2012

Chief complaint(s):
1) Vomiting for 1 day duration
2) Fever for 1 day duration
History of Presenting Illness:
He was apparently well until afternoon prior to admission when he started to vomit.
The vomiting was abrupt in onset. The mother denied any history of trauma to her
sons head and it is not projectile vomiting. The mother did not remember how
many time her son vomit but she claimed it is more than ten times. The vomitus
contains milk that the patient drink and the mother denied any presence of blood,
mucus or bilious material. The amount of vomitus was the same amount with what
the patient had drank. The patient can not eat or drink anything because when he
started to drink his milk, he will vomit. Because her son can not drink the milk, the
mother gave glucose water to replenish the fluid loss. However, the patient also will
vomit out the glucose water. Upon questioning, the patient was on bottle feeding.
The mother claimed that she boiled the bottle every time she wanted to give milk to
her son.
Besides, the patient also develops fever on the same day with vomiting. According
to the mother, the fever was a high grade fever because when she touched her
sons body, it was too hot. However, there is no recorded body temperature. The
fever is not associated with chills and rigor. The mother also denied any episodes of
seizure during that febrile period.

Upon further questioning, the mother denied her son develop the same illness
before. The mother denied her son had taken any other foods except the formulated
milk that she gave to her son. There are no other family members who develop the
same illness. She also denied any recent travel to endemic areas. The mother also
claimed that her son was not on medication previously. The mother did not know
whether her son had developed reduced in urine output during that period of
vomiting and fever because he wore diapers. However she claimed that her sons
urine output was normal. She also claimed that there is presence of tears when her
son cries. The mother also denied her son appears thirsty. Because of her sons
condition, she went to Klinik Kesihatan Karak and was given intravenous fluid and
immediately was sent to Hospital Sultan Haji Ahmad Shah (HoSHAS) in the evening.
At the hospital, the fever and vomiting stop. However her son develop diarrhea at
night on the day of admission. The diarrhea occurs for about 4 times and the stool
was loose. The mother claimed that the stool was foul in smell and she denied any
presence of blood or mucus in the stool and the diapers are fully soaked with stool.
Systemic Review:
General: He appears lethargic and unresponsive to the surrounding
Cardiovascular: No cyanosis, no dyspnoea
Respiratory: No stridor, no wheezing, no runny nose. Presence of suprasternal and
substernal recession
Gastrointestinal and Hepatobiliary: no jaundice, no abdominal pain, only present
with diarrhea.
Neurological: no altered consciousness, no confusion, no seizure, no headache
Haemopoeitic : No pallor, no bleeding tendencies.
Musculoskeletal: no muscle cramps, no stiffness, no arthralgia, no myalgia
Skin: no pigmentation, no rash, no pruritus
ENT: presence of cuts at the back of ear pinna.
Past Medical History:
He was a known case of congenital heart disease diagnosed after delivery with
perimembranous ventricular septal defect. He was a follow up case from HoSHAS
and National Heart Institute. According to the mother, the opening was so small and
there is no correction has been done and the doctor will monitor her son until her
son grow up.
Birth History:

Antenatal: Uneventful. The mother did not develop any complications during her
antenatal period
Perinatal: The patient is termed baby born at 40 weeks of gestation through
caesarean section delivery because of fetal distress (presence meconial fluid). The
birth weight of the patient at the time of delivery was 2.8 kilogram.
Postnatal: The patient had been diagnosed to have congenital heart disease
specifically, perimembranous ventricular septal defect.

Immunisation History:
The patient had receives complete immunization required up to his age.
Developmental History:
Gross motor: can walk by holding something, can prone and lift his head up
Fine motor: positive palmar grip
Speech and Language: can say mama and baba
Social: can smile and can understand what the mother talks.
Nutritional History:
He was breastfed for only two weeks. The mother claimed that the patient refuse to
be breast fed. Then, she gave her son formulated milk.
His weaning diet started at 6 month old. Initially the mother gave the patient rice.
However the mother said that her son stool was hard in consistency after giving the
rice. Then she changed his son diet by giving porridge until 10 month old. Currently,
she only gives her child formulated milk.
Family History:

27 years old

24 years old

1 year month
The patient is the only child in the family. His father is a lorry driver and his mother
is a housewife and it is a consanguineous marriage. Both the father and mother are

well and healthy. On maternal side, the grandfather has hypertension and the
grandmother is healthy. However, the mother did not know whether the
grandparents on the paternal side have any illnesses.
Social History:
The patient and his family live in a brick house at Ladang Tuan at Karak. The mother
did not know how long it takes to travel from Karak to HoSHAS. The paternal mother
and aunt live together with them. The mother claimed that the house has a good
water and electricity supply. The father is a smoker and he smokes less than one
pack per day and he does not drink alcohol. The income for family is RM35 per day
and about RM500 per month.
Drug history:
He does not have any known drug allergy and he do not on medication currently.
Physical Examination
Generally, he was unconscious and not alert to the surrounding. His hydration
status is not good because there were sunken eye and dry lips and mucous
membrane. However the skin turgidity is normal. There was no pallor, clubbing,
cyanosis or ankle oedema. No congenital defects detected. Lymph nodes are not
palpable.
Vital signs:
Blood pressure: 90/52 mm/Hg
Temperature: 37c
Respiratory rate: 31 breaths per minute
Pulse rate: 113 beat per minute
Anthropometry measurements:
Weight: 5.85 kg (below 3rd centile)
Height: 71 cm (between 3rd and 10th centile)
Head circumference: 40 cm (below 2nd centile)
Skin:
The skin is pink in colour, soft and warm. The skin turgor is normal. There are no
rashes, bruises, hyperpigmentation or hypopigmentation.
Head and neck:

The size and shape of the head is normal. There is no hydrocephalus, microcephaly
and syndromic facies. There is no sunken fontanelle.
Eye:
There is no jaundice detected on the sclera of the eye. No nystagmus or squint
detected. There is no presence of pallor on conjunctiva. However, there is presence
of sunken eye.
Ears:
No discharge detected. However there is cuts presence at the back of ear pinna
Nose and sinuses:
No discharge and bleeding detected.
Mouth:
No abnormalities detected. No central cyanosis. Lips and mucous membrane is a
bit dry.
Systemic review:
Cardiovascular system:
Inspection: There is no chest deformity, no scars, no dilated veins and the chest
move symmetrically. Palpation: The apex beat is located at 4 th intercostals space
at
midclavicular
line.
There
is
no
thrill
and
parastenal
heave.
Auscultation: first and second heart sound is heard. There is presence of
pansystolic murmur heard at lower left sternal margin
Respiratory system:
Inspection: There is no chest deformity, no scars and no dilated veins. There are
presence of suprasternal and substernal recessions. There is no using of accessory
muscle of respiration.The chest moves symmetrically with respiration.
Palpation: There is no cervical lymphadenopathy and the chest expansion is
normal.
Percussion: Not done because the patient appears
lethargic and restlessness
Auscultation:
There is vesicular breath sound and there is no added sound is heard.
Abdomen:
Inspection: There is no gross enlargement of the abdomen, no scars and no dilated
vein. The umbilicus is centrally located and inverted. The abdomen moves
symmetrically with respiration.
Palpation: The abdomen is soft and
non-tender. The liver is not palpable and the kidney is not ballotable. Auscultation:
There is increase bowel sound.

Haemopoeitic system:
He was not pale and jaundice. There was no petechial, ecchymoses, bruising and
bleeding. No enlarged lymph nodes and bony tenderness can be palpated.
Musculoskeletal system:
On inspection there is no obvious deformity observed. No tenderness and swelling.
Muscle wasting is not present.
Central nervous system:
The patient is unresponsive and not alert to the surrounding.

Case summary:
Sharvin S/O Panmiselvam, 1 year month old Indian boy presented to HoSHAS with
vomiting and fever for one day duration prior to admission. The boy started with
vomiting and fever in the afternoon prior to admission. The vomitus only contains
milk that the boy drank and it is not projectile in nature. He vomits more than ten
times. The fever was a high grade fever and it is not associated with chills and rigor.
This was the first time he had this illness and there is no history of eating outside
foods or travelling to endemic areas with diarrhea and there is no other family
members who develop the same illness. At the hospital, fever and vomiting stops
but he developed diarrhea. The stool was loose and it is not associated with blood.
On examination, the patient is lethargic and not alert to the surrounding. There was
sunken eye and dryness of lips and mucous membrane. Other systems were normal

Provisional Diagnosis:
Acute gastroenteritis with 7.5% dehydration
Differential diagnosis:
1)
2)
3)
4)

Acute gastroentritis
Bacterial infection
Viral infection
Parasitic infestation

5) Lactose intolerance
Discussion of differential diagnosis
N
o
1

Differential
diagnosis
Acute
gastroenteritis

Points for

Viral infection

Bacterial
infection

Parasitic
infestation
Lactose
intolerance

1)
2)
3)
1)
2)
3)
1)
2)
1)
2)

1)
2)
3)
4)

Points against

Vomiting
Diarrhea
Acute in onset
Fever

Age
Vomiting
diarrhoea
High grade fever
Vomiting
Diarrhea
vomiting
diarrhoea
Age
Occur after drink
milk
3) Watery diarrhea

1) No recent travelling to
endemic areas
2) Not taking any other foods
3) No family members who had
the same illness
1) High grade fever
1) No blood in stool
1) No history of family with
parasitic infestation
1) No abdominal distention
2) No flatulence
3) No abdominal pain

Investigations:
Full blood count:
Reason(s):
1) To look for evidence of increase in white blood cell especially neutrophil that
indicate bacterial infection, eosinophil to indicate parasitic infestation and
leukocyte to indicate viral infection.
2) To look for any signs of anemia
Result:
Hb: 12.3 g/dL (N: 10.5-14.0 g/dL)
Total white blood cell: 10.5 g/dL (N: 6.0-15.0 g/dL)
Platelet: 397 X 10 ( N: 150-450 X 10^9)
Comments: All the components are in normal range. Therefore, we can say that
there is no sign of infection and anemia

Blood Urea Serum Electrolyte (BUSE):

Reason(s):
1) To detect any electrolyte imbalance due to dehydration
Result:
Urea: 5.2 (N: 5-18 mg/dL)
Sodium: 134 (N: 139-146 mmol/L)
Potassium: 4.17 (N:3.5-5.0 mmol/L)
Creatinine: 107 (N:44-133 mmol/L)
Comments: There is presence of hyponatremia. This is due to loss of sodium
through vomiting and diarrhea
Stool culture:
Reason(s):
1) To detect any presence of ova and cyst that indicate infection or infestation
Result:
Pending
Progression in the ward:
On the day of admission, the patient appeared lethargic and dehydrated. There is
evidence of sunken eye and dryness of lips and mucous membrane. He was given
intravenous fluid of dextrose because of hypoglycemic condition. A dextrostic chart
was made to monitor his hypoglycemic condition. At the hospital, the vomiting and
fever stopped. However, he developed diarrhea at night on the same day of
admission.
On the second day, he was given intravenous infusion of sodium chloride 0.45% and
dextrose 5%. The mother also claimed that the patient had passed out faeces more
than 6 times. A nasogastric tube had been inserted in order to give milk to the
patient. The patient still floppy and not alert to the surrounding.
On the third day, the patient still in intravenous fluid infusion. The diarrheic
condition continues but the stool was a bit hard and the frequency had reduced. His
condition also is getting better. The lips were a bit moist and he response by moving
his eye when his name was called.

Final diagnosis:
Acute gastroenteritis with 7.5 % dehydration

Discussion:
Acute gastroenteritis is a leading cause of childhood morbidity and mortality and is
also an important cause of malnutrition. Acute gastroenteritis can be defined as
diarrheal disease of rapid onset, with or without accompanying symptoms such as
nausea, vomiting, fever, or abdominal pain. In developing countries, gastroenteritis
remains a major cause of mortality while in developed countries, it is a cause of
morbidity, particularly in younger children. The major mechanisms of transmission
for diarrheal pathogens are person-to-person through fecal-oral route or by
ingestion of contaminated food or water. However there is also extraintestinal
infection related to bacterial enteric pathogen.
The main causes of gastroenteritis is due to viral infection particularly rotavirus and
norwalk virus. However there is also infection with bacteria and parasite. Bacterial
causes usually due to aeromonas, Campylobacter jejuni,enteroinvasie E.coli,
Shigella and Salmonella. Parasitic causes include Giardia lamblia and Entamoeba
histolytica
Clinical manifestations depend on the organism and host response to infection and
include asymptomatic infection, watery diarrhea, bloody diarrhea, chronic diarrhea
and extraintestinal manifestation of infection.
Laboratory studied used to identify diarrheal pathogen are often not required
because most episodes are self limited. All patients with diarrhea required fluid and
electrolyte therapy, a few need other non-specific therapy support and some may
benefit from antimicrobial therapy

The main objectives in the approach to a child with acute diarrhea are
1) To assess the degree of dehydration and provide fluid and electrolyte
replacement
2) Prevent spread of the enteropathogen
3) In select episodes determine the etiologic agent and provide specific therapy
if indicated.
Information about oral intake, frequency and volume of stool output, general
appearance and activity of child and frequency of urination must be obtained. Data
should be obtained about childcare centre attendance, recent travel to a diarrhea
endemic area, use of antimicrobial agent, exposure to contact with similar
symptoms, intake of seafood, unwashed vegetables, unpasteurized milk,

contaminated water or uncooked milk. Duration and severity of diarrhea, stool

consistency, presence of mucus and blood and other associated symptomatology ,
such as fever, vomiting and seizure should be determined.
References:
1)
2)
3)
4)
5)
.

Nelson Textbook of Paediatrics, 17th edition

Illustrated Textbook of Paediatrics, 4th edition
Paediatric Protocol, 2nd edition
Hutchisons Clinical Methods,23rd edition
Systemic Paediatric Physical Examination by Zainab Kassim