Judul: Pedia Patient002 copy
Penulis: Weng Evangelista
Date of Interview: June 18, 2015
Time of Interview: 4:30 – 6:30 PM
Informant: M. BatallerRelationship of informants: Grandmother of the Patient
% Reliability: 75 %
A. D., the patient, is a 1 year and 8 month old, Filipino female, born September 10, 2013, living at 565 Valderama St., Binondo, Manila, Roman Catholic, and is currently admitted for the first time at Ospital ng Maynila Medical Center last May 30, 2015 at 12mn.
History of Present Illness
1 day prior to admission, the patient experienced loss of appetite and decreased physical activity. No consultation was done.
8 hours prior to admission, the patient experienced diarrhea characterized as green, watery and mucoid. According to the informant, the patient defecated about ½ cup or about 125 ml, 3-5 times a day. They changed the diapers of the patient about 4-5 times in a day. In addition, the diarrhea had no specific onset. No management was done at home to provide relief. However, this was accompanied by generalized weakness, dysphagia (with a preference for soft foods), and black-colored lips. No fever, abdominal pain, and jaundice was noted.
Review of Systems
General (+) weight loss, chronic, first noticed when the patient is 1 year old
(+) night sweats
Cutaneous(-) rash, pigmentation, hair loss, pruritusHEENT (+) lumps in the head
(-) headache, dizziness
(-) visual difficulty, lacrimation(-) nasal disharge, epistaxis(-) toothache, salivation, sore throat
(+) bleeding gums, especially when brushing the teeth
Cardiovascular (-) easy fatigbality(+) cyanosis
(-) fainting spells
Respiratory (+) productive cough, sputum whitish, no blood was noted, with an unknown amount
Genitourinary (-) dysuria, discharge, enuresis
(-) edema of hands and feet
Endocrine (-) cold/ heat intolerance
Nervous/Behavioral (-) tremors, paralysis, convulsions
Musculoskeletal (-) pain / swelling in bones, joints, muscles
(-) limitation of motion, stiffness
Hematopoietic (-) pallor, easy bruisabilityPersonal and Social History
Gestational and Birth History:
The mother was a 32 year-old, G5P5 and gave birth to the patient via Normal Spontaneous Delivery, full term. The informant failed to describe the health and nutritional status at the time of gestation. The birth weight was also unrecalled.
The patient was exclusively breast fed since birth until the patient was 1 year old. At 1 year old, the patient was bottle fed, with 3-4 scoops of powdered milk diluted in 3 ounces of water. The patient was bottle fed 3 times a day.
At 1 year old, cerelac was introduced, consuming approximately 300 grams per day. Other foods introduced were mashed banana and rice. The frequency of feeding these foods was not stated by the informant. The patient does not take any vitamins. No food intolerance or allergy was noted.
The patient can creep and sit with support. However, at her age, the patient cannot sit without support, cannot stand on her own, and cannot walk. Aside from crying and cooing, the only words that the patient verbalizes are "mama and dada." Exhibits visual tracking of objects, good head control on prone and sitting positions, and sustained midline regard.
According to the informant, the patient has Primary Complex but the date of diagnosis was unrecalled as well as the duration of treatment. The patient is currently taking Isoniazid and Rifampicin.
The informant claimed that the patient had 1 dose of BGC, 3 doses of OPV, 3 doses of Hepa B, 1 dose of Measles vaccine. All of the vaccines were administered at the health center.
The mother of the patient is currently 34 years old, while the father was in his late 20's. Both parents of the patient have no permanent jobs. However, the father of the patient works as a construction worker whenever work is available. No health problems were noted. The patient has 4 siblings. The eldest, male, died (at 12 years old) due to drowning, while the other three: one female at 12 years old, one male at 11 years old, and one female at 7 years old, have no health problems. The siblings help their mother in taking care of their child. According to the informant, no other family member has a history of Tuberculosis, Diabetes, or Hypertension.
The house they live in was a two-storey, 20 ft square home, comparable to the room in the wards. They described the house as well-ventilated. However, 9 persons are currently living inside the house.
The grandfather was a chain-smoker but the informant failed to state the number of sticks he consumes in a day. He preferred to smoke inside the house. Two of their neighbors, who were always interacting with the patient, were reported to have active Tuberculosis.
Their water source comes from NAWASA via tap water, used for both drinking and washing items at home. Their drinking water was not boiled. Garbage was collected weekly via truck.
The patient was conscious but sluggish. She was unkempt and in distress. She appeared undernourished, ill-looking, and looked older for her age. The patient also appeared dehydrated, and thirsty. She was irritable and was whimpering.
HEART RATE: 144 bpm, regular
RESPIRATORY RATE: 45 rpm, regular
TEMPERATURE: 37.1°C (axillary)
The vital signs were taken while the child was quiet and lying on the bed. Based on the Acute Illness Observational Scale, the patient had a whimpering cry, cries off and on, easily awaken from sleep, with pale hands and feet, the skin was doughy and the eyes were sunken with dry eyes and mouth. The patient was anxious and appeared in distress.
LENGTH: 63.5 cm
HEAD CIRCUM: 38.1 cm
CHEST CIRCUM: 36 cm
ABDOMINAL CIRCUM: 33.02 cm
MUAC: 5.588 cm
See WHO Growth Charts for Interpretation of Anthropometric Data.
Patient's skin is fair, pale, dry, wrinkled, with tented and doughy skin, exhibiting poor turgor. There is no, jaundice, or abnormal pigmentation. Marked loss of subcutaneous fat or tissue was observed. Nail beds were pale and negative for clubbing.
Head is normocepahlic. No palpable masses and no tenderness. Hair is black, fine, and thin. No scaling, pigmentation or infection of the scalp was noted. The scalp has no masses or lesions. The anterior fontanel was not closed, and was sunken and in midline. No facial deformities was observed.
Eyebrows are symmetrical with equal distribution. Both eyes have anicteric sclera, clear cornea and pale palpebral conjunctiva. No redness or discharge on both eyes. Pupils are equally round. Patient blinks when light or an object is shown. Eyes turn into the direction of an object shown or to the sight of the grandmother. Tests for accommodation and confrontation not done. Fundoscopy not done.EARS:
Both ears are symmetrical. No masses on both auricles. No discharge, redness nor tenderness noted on both ears. Turns head towards grandmother's voice.
The septum was in midline. There was no alar flaring, discharge, redness or swelling.
MOUTH and THROAT:
The lips were pale, dry, and with no lesions. The patient has 7 front teeth (4 incisors at the upper jaw and 3 incisors as the lower jaw). The gums were pale with no sores and ulcerations. The tongue was in midline. No atrophy, fasciculations, enlargement or lesions were observed. The tonsils were not enlarged. The uvula was in midline.
The lymph nodes were not palpable. There was no tenderness, mass, swelling, or lesions. The trachea was in midline. The thyroid was not palpable.
CHEST and LUNGS:
The patient had a symmetrical chest expansion, with an AP Ratio of 2:1 The patient was in respiratory distress and used accessory muscles. Subcostal and intercostals retractions were present. The chest veins are not prominent. There were no visible scars, masses, and lesions. There was no tenderness upon palpation on both anterior and posterior chest. Crackles were heard upon auscultation over all lung fields.
Precordial area flat, adynamic, and there were no lifts, thrills, heaves, tenderness. No heaves or thrills, PMI is brisk at 4th ICS on the LMCL. Crisp S1 and S2. At the base, S2 is greater than S1, while at the apex, S1 is greater than S2. There were no extra sounds and murmurs.
The abdomen was flat, with no visible peristaltic movements or visible pulsations. The umbilicus was inverted and midline. Normoactive bowel sounds noted at 8 per minute. Tympanitic upon percussion over all quadrants. No tenderness and masses were felt upon palpation.
BACK AND EXTREMITIES:
(-) nail clubbing; capillary refill: 1 sec. Symmetrical, regular, strong peripheral pulses. There was no joint swelling, tenderness, crepitation, stiffness. The spine was in midline. Peripheral pulses not assessed.
There is symmetry of muscle atrophy with muscles looking flat or concave and hypotonic. No involuntary movements observed. No tremors and fasciculations were observed. Muscle strength of 3/5, becoming active only against gravity.
Diarrheal disorders in childhood is the second most common cause of child deaths worldwide, with approximately 0.71 million deaths per year globally CITATION Kli16 \l 1033 (Kliegman, 2016). Diarrhea is defined by the World Health Organization as the passage of three or more loose, watery stools per day. Acute diarrhea is considered if the duration of symptoms is less than 2 weeks. It is important to properly assess and promptly treat a child with diarrhea as severe dehydration and electrolyte imbalance are common sequelae CITATION Kli16 \l 1033 (Kliegman, 2016). Based on the patient's clinical history, the following differential diagnoses were elucidated in order to arrive at a clinical impression.
A. Acute GastroenteritsInfections of the gastrointestinal tract, termed gastroenteritis, may be caused by bacterial, viral, or parasitic pathogens CITATION Kli16 \l 1033 (Kliegman, 2016). These pathogens are usually foodborne or waterborne, and the etiology can be identified through the patient's signs and symptoms CITATION Kli16 \l 1033 (Kliegman, 2016). The most common of which, are diarrhea and vomiting. It is associated with a poor feeding and nutritional history, poverty, poor environmental hygiene, and developmental delays CITATION Kli16 \l 1033 (Kliegman, 2016).
B. Inflammatory Bowel Disease
Inflammatory Bowel Disease is an idiopathic disease caused by an impaired immune response to a patient's intestinal microflora CITATION Med15 \l 1033 (Medscape, Inflammatory Bowel Disease, 2015). There are two major types of IBD: ulcerative colitis, which usually affects the large intestine, and Crohn Disease, which affects any segment of the GI tract, and has skip lesions CITATION Kli16 \l 1033 (Kliegman, 2016). The disease affects both male and female equally with a peak incidence of late adolescence to the third decade of life CITATION Kli16 \l 1033 (Kliegman, 2016). Abdominal cramps, recurrent abdominal pain, and diarrhea are the common clinical manifestations of the disease.
C. Food-Protein Intolerance
Among the many food proteins that are antigenic in humans, cow's milk has been determined as one of the leading causes of food intolerance during infancy CITATION Med141 \l 1033 (Medscape, Protein Intolerance, 2014). Complementary foods can also be a source of proteins that are antigenic or allergic to an infant as it is introduced. Food protein intolerance can be IgE-mediated or non-IgE mediated CITATION Med141 \l 1033 (Medscape, Protein Intolerance, 2014). Gastrointestinal symptoms account for 50-80% of the clinical manifestations of the disease, with respiratory symptoms accounting for 4-25% CITATION Med141 \l 1033 (Medscape, Protein Intolerance, 2014).
D. Urinary Tract Infection
According to a study by Fallahzadeh and Ghane (2006), children presenting with acute diarrhea should be investigated in children with acute diarrhea especially for those female infants aged 5-15 months. In their study, patients with acute or persistent diarrhea, UTI was positively correlated. The same microorganism implicated in UTI such as E. coli, may be the same bacteria causing diarrhea in children and vice versa. Majority of patient aged 2 months – 2 years old may lack symptoms localized to the urinary tract; however, children aged 1-2 years old usually presents with cystitis CITATION Med151 \l 1033 (Medscape, Pediatric Urinary Tract Infection, 2015). The patient may present with fever, poor feeding, irritability, and failure to thrive CITATION Med151 \l 1033 (Medscape, Pediatric Urinary Tract Infection, 2015).
Table SEQ Table \* ARABIC 1. Differential Diagnoses of Diarrhea
Rule In Rule Against
Acute Gastroenteritis Onset: within hours to days
Fever usually present
Associated with poor feeding history (poor breastfeeding)
Unboiled water for drinking may harbor pathogens
Developmental delays (growth retardation) common
Severe malnutrition and dehydration present Cannot be ruled against
B. Inflammatory Bowel Disease Diarrhea: mucus may be present in the stool
Fever usually present
Generalized weakness present
Dehydration and pallor may be present
Growth retardation common Peak incidence of Late Adolescence (patient is less than 2 years old)
Associated symptoms of arthralgias and liver disease not present
Gross bloody stools are not present (watery, mucoid stools are present in the patient)
Onset and duration of illness may be months to years (the onset of the patient's condition is acute)
C. Food-Protein Intolerance/ Food Allergy Diarrhea
DysphagiaWeight loss may be present
Dehydration usually present
Growth retardation may occur
Complementary foods already introduced Age of onset usually 6 months or younger who was fed with a formula (patient has been formula-fed for 8 months)
The patient has no history of food avoidance
D. Urinary Tract Infection Associated with poor feeding history
Diarrhea and loose stool
Irritability The patient did not manifest with fever
Dysuria was not present in the patient as well as voiding alterations
Based on the Clinical History and Differential Diagnostic study of the patient, the clinical impression of Acute Gastroenteritis was made. The onset and duration of 1-2 days was critical in properly diagnosing the condition of the patient. Based on the associated signs from the physical examination, an evaluation of severe malnutrition can be made which further predisposes the patient to infection CITATION Kli16 \l 1033 (Kliegman, 2016). The absence of high grade fever and bloody stools, and the presence of watery-mucoid stools would probably categorize the condition as Non-Inflammatory CITATION Kli16 \l 1033 (Kliegman, 2016). However, further work-up is needed to determine the specific etiologic agent.
Co-Morbidity: Severe Chronic Malnutrition, MarasmusBased on the Anthropometric Data of the patient, a diagnosis of Severe Malnutrition was made. The diagnosis of chronic malnutrition is based on the Length-For-Age Growth Chart of the WHO (See growth charts). With a z-score of less than -3, the patient exhibited stunting or growth failure. The reason is that the patient had a poor feeding history and practice, including the quality of food taken. In addition, based on the patient's z-score of -3 on the Weight-for-Height Growth Chart of the WHO (See growth charts), the patient also exhibits wasting, which is also probably chronic.
Based on the patient's clinical history, a diagnosis of Marasmus can also be made. Marasmus is one of the clinical forms of serious Protein-Energy Malnutrition CITATION UNI15 \l 1033 (UNICEF). This condition mainly manifests in young children and the inadequacy of nutrient intake, of protein and carbohydrates, can predispose a child to malnutrition which would in turn, affect his or her immune status CITATION UNI15 \l 1033 (UNICEF). Marasmus is most frequently associated with acute infections such as gastroenteritis, respiratory illness, and measles. It is characterized by extreme emaciation, reduction in fat and muscle, dehydration, and an "old man's appearance CITATION UNI15 \l 1033 (UNICEF)." The patient is also alert and irritable. All these signs were manifested by the patient.
Acute Gastroenteritis, Probably Non-Inflammatory with Severe Chronic Malnutrition, MarasmusAcute Gastroenteritis, Probably Non-Inflammatory with underlying Severe Chronic Malnutrition
PathophysiologyThe underlying Chronic Malnutrition predisposes the patient to increased susceptibility to a variety of infections. Depending on the microorganism involved, the pathogenesis and severity of the condition varies. Noninflammatory diarrhea are usually caused by enterotoxins, while Inflammatory diarrhea are cause by cytotoxins CITATION Kli16 \l 1033 (Kliegman, 2016). Several organisms elaborate enterotoxins such as S. aureus and Bacillus cereus; V. cholera, E. coli, and Salmonella produce secretory toxins, while Shigella and C. jejuni produce cytotoxins and are invasive CITATION Kli16 \l 1033 (Kliegman, 2016). In addition, viruses such as Rotavirus and Norwalk Virus target the microvillus of enterocytes affecting the absorption throughout the length of the intestines. Parasitic infections are also common such as Giardia lamblia and Entameoba histolytica CITATION Kli16 \l 1033 (Kliegman, 2016).
Based on the clinical history of the patient, it is probable that either Osmotic Diarrhea or Secretory Diarrhea (both Non-Inflammatory Types) could be the main pathophysiological alteration present. In Osmotic Diarrhea, an ingested solute that is poorly absorbed stays in the gastric lumen. This creates a higher concentration gradient within the gut lumen drawing water into the intestinal lumen. This increases the water content of the stool. Rotavirus infections caused by its protein NSP4 is one such example CITATION Kli16 \l 1033 (Kliegman, 2016). On the other hand, Secretory diarrhea is usually caused by preformed enterotoxins by infections such as Cholera and S. aureus. Bacterial enterotoxins activate enterocyte intracellular signal transduction, altering the membrane potential of ion channels. Thus, water and electrolyte exchange is altered CITATION Kli16 \l 1033 (Kliegman, 2016).
The onset of diarrhea and gastrointestinal manifestations depend on the organism involved. In the patient with a history of 1-2 days of diarrhea, infections due to S. aureus can be considered CITATION Kli16 \l 1033 (Kliegman, 2016). Whatever the cause, the absorption of water and electrolytes becomes a major problem especially in pediatric patients CITATION Kli16 \l 1033 (Kliegman, 2016). The reason is that the rate of volume depletion is more rapid in children than adults due to the increased surface to volume ratio and limited renal compensatory capacity. Thus, dehydration ensues without appropriate and prompt management CITATION Kli16 \l 1033 (Kliegman, 2016).
Management and Treatment
Based on the natural history of the condition, the goals of treatment then is the prevention of severe dehydration of the patient and the prevention of sepsis. Taken into consideration is the nutritional status of the patient who appears to be marasmic and malnourished based on the clinical history. Oral rehydration and proper nutrition is thus important for this patient. The table below shows the Plan of Care and Management for the Patient CITATION Kli16 \l 1033 (Kliegman, 2016).
Table SEQ Table \* ARABIC 2. Management and Treatment Plan for Patient, A.D.
Goal Objectives Interventions
At the end of the intervention period, the patient recover from diarrhea At the end of the week, the patient would pass soft, formed stool no more than 3 times per day.
At the end of 2 weeks, the patient would have negative stool cultures.
At the end of the intervention, the patient would not manifest signs of sepsis. Assessment and Monitoring:
Monitor for signs and symptoms of further gastrointestinal disturbances such as:
Nausea and Vomiting
Abdominal Cramps which can manifest as Irritability and Crying
Determine the etiologic agent through diagnostic exams (culture)
Administer antibiotics based on the results of the culture
At the end of the intervention period, the patient would have an improved hydration status. At the end of the initial treatment of 1-2 days, the patient would have no symptoms of dehydration, hypothermia, and hypoglycemia.
Assessment and Monitoring:
Continuously assess the hydration status as to the following:
General Appearance and Level of Consciousness
Normal and Appropriate Vital Signs
FontanellesSkin TurgorMoisture of mucous membranes
Provide Oral Rehydration Therapy (Oresol)
At the end of 6 weeks of intervention, the patient would not manifest any electrolyte imbalances
Assesment and Monitoring
Monitor Intake and Ouput
Monitor Electrolyte Levels
Continue the provision of Oral Rehydration Therapy
At the end of the intervention period, the patient would have an improved nutritional status. At the end of the week, the patient would have an increased appetite and tolerance to feeding.
Assessment and Monitoring:
Continuously assess for the following:
Intolerance and Response to Food
Anthropometric Data especially weight
Monitor for adequacy of caloric intake
2. Assess for failure to thrive
Initiate and begin breastfeeding
Provide Oral Rehydration Therapy (Oresol)
Correct micronutrient deficiencies
At the end of 6 weeks of intervention, the patient would manifest catch-up growth. Assessment and Monitoring:
Monitor for signs refeeding syndrome after the first-second week of intervention
Increase feeding gradually to recover lost weight
Resume age-appropriate normal diet (continue introduced complementary foods)
Provide supplementation with vitamins and minerals
At the end of the intervention, the patient would exhibit improved developmental and growth indices. Evaluate for further delays in development
Evaluate the patient's anthropometrics using the WHO growth charts.
Provide a stimulating environment for the patient
At the end of the intervention, the caregivers of the patient would have an increased knowledge and skills about Nutritional and Dehydration Management. Home Care Management Teach and Inform the Caregivers About the Following:
Importance of Exclusive Breastfeeding
Proper introduction of Complementary Foods Practice
Signs and symptoms of Food Intolerance and Food Allergies
Signs and symptoms of Dehydration including when to bring the patient to a Hospital or Clinic
Preparation of OresolImportance of Hygiene, especially perianal hygiene after each bowel movement
Importance of a safe drinking Water Source
Immunization Completion (Rotavirus, etc)
BIBLIOGRAPHY Churgay, C. A., & Aftab, Z. (2012). Gastroenteritis in Children. American Family Physician , 1059-1062.
Elliot, E. J. (2007). Acute Gastroenteritis in Childen. British Medical Journal , 35-40.
Kliegman, R. M. (2016). Nelson Textbook of Pediatrics Twentieth Edition. Philadelphia: Elsevier.
Medscape. (2015, January 7). Inflammatory Bowel Disease. Retrieved June 18, 2015, from Medscape: http://emedicine.medscape.com/article/179037-overview
Medscape. (2015, June 18). Pediatric Urinary Tract Infection. Retrieved June 18, 2015, from Medscape: http://emedicine.medscape.com/article/969643-clinical
Medscape. (2014, August 01). Protein Intolerance. Retrieved June 18, 2015, from Medscape: http://emedicine.medscape.com/article/931548-overview
Organization, W. H. (n.d.). Nutrition. Retrieved June 18, 2015, from World Health Organization: http://www.who.int/nutrition/topics/malnutrition/en/
UNICEF. (n.d.). Nutrition . Retrieved June 18, 2015, from Unicef: http://www.unicef.org/nutrition/training/2.3/1.html
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