CRIMEA STATE MEDICAL UNIVERSITY

Named after S. I Georgievsky

Department of Children Infectious Diseases.

Head of department : I.V. Bogadelnikov

Teacher : Elena Alexandrovna

CASE REPORT

Patient’s full name : lila Eugenia vladimirovna

Clinical diagnosis:
Main disease :Acute Gastroenteric Disease with Toxicosis

Complications : none
Accompanying diseases : none

Student : Gobi Marathamuthu

Group : 538

I. PASSPORT DATA
Patients’s Name : Lila Eugenia Vladimirovna
Age : 1 year and 8 months old
Sex : Female
Date of Birth : 25/10/2005
Nationality : Ukrainian
Marital status : Single
Address : Podikova17-18,Simferopol
Date of Admission : 28/05/07

II. INQUIRY (INTERROGATIO)

COMPLAINTS : ( Taken from the mother )

Patient complains of cramping pain at the lower part of the abdomen
accompanied with nausea. Patient also complains of diarrhea with
watery stools 3-4 times aday.She was crying after some meals.
Appetite is less. Patient vomited more than 7-8 times. She feels
weak accompanied with headache with dizziness.She also had
regurgitation and throat ache.He felt weakness along this period.Her
temperature was 38.0.

III. HISTORY OF PRESENT DISEASE ( ANAMNESIS MORBI )

The patient’s mother bought some fruits from the market and
gave it to her and the patient’s sister.After several hours they both
started to vomiting. Then this was continued with a series of
diarrheas.She also started to cry often.Mother was worried and
decided to bring her to the hospital.

IV. EPIDEMIOLOGICAL ANAMNESIS

Other than her sister ,none of the other family members have the
same problems.Only both of them seems to be vomiting and constant
diarrheas.The symptoms all apparently only started after the taking of fruits

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that was bought by the mother from the market.All other food taken before
this was homely prepared by the mother herself.
She does not have any pets therefore he does not have any sort of contact
with animals or rodents. She also has not traveled outside the country . This
incident took place after she had pelmini at the Simferopol. She does not
recall eating any poor quality products except for the watermelon. He
washes his fruits and vegetables. She drinks water that is ordered from the
company. There were no injuries or wounds, abrasions or any scratches on
his skin. She washes his hands before meals.

V. LIFE HISTORY ( ANAMNESIS VITAE )

The patient was born in Simferopol as the second of two children. She has a
older sister who is 3 years old and is said to be healthy. The patient began
walking and talking on time, she was also breastfed. Conditions of her
childhood was satisfactory.The patient’s parents are both working as guard
and house wife. Her father’s age is 28 and his mother is 28 years old.. Other
than that both the parents are healthy and do not have any other diseases.
The patient has a normal appetite. She eats about 3-5 times a day. She
likes to eat particularly meat. She goes to the toilet regularly as well. She
sleeps well during the nights.
She does not suffer from any past illness such as tuberculosis,
hepatitis, thyphus, malaria or diabetes. She has had no blood transfusion
before.

3. DATA OF PHYSICAL EXAMINATION ( STATUS PRAESENS)

General condition of the patient is satisfactory. Consciousness is clear,

posture is active, gait not changed. Facial expression is healthy. Body
structure is normosthenic. Her skin was full of blister. Lips are normal, other
visible mucosa are pinkish and moist. Submandibular, cervical and axillary
lymph nodes are determined from 0.5-1.5cm in diameter, rounded form with
smooth surface, elastic consistence, mobile, not adhered to the skin,
surrounding subcutaneous fat. Skin over them is not changed.
The muscles are developed moderately. Tone and muscles are
identical on both sides. Palpation and tapping of bones are painless, joints
are of regular shape and painless during palpation and movements.
Temperature and skin over them have not changed. Active and passive
movements in joints are full. Pathologic deformations of the spinal column
are absent. Its function is normal.
Temperature of body - 38ºC
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 Height – 63 cm
Weight – 8 kg’s

RESPIRATORY SYSTEM

Patient breathes through the nose. Nose wings does not participate in
the breathing. Voice is normal. Form of the chest is regular & normosthenic
and the epigastric angle is 90 degrees. The chest is symmetrical.
Supraclavicular fossae are pronounced. The ribs are moderately inclined as
viewed from the side , shoulder blades closely fit into chest and are on the
same level. Respiration type is abdominal. Breathing is rhythmic.
Respiratory rate is 20 per minute. Inspiration and expiration are equal.
In comparative percussion of the lungs, the percussion sound is symmetrical.
Clear lung sound over the other parts of the chest. Traube’s space gives
tympanic sound.
The upper level of the apices on both sides anteriorly is 1cm,
posteriorly it is at the level of the spinal process of the 7th cervical vertebrae.

Lower borders of the lungs:

LINES RIGHT LUNG LEFT LUNG

th
Parasternal 5 rib -
th
Mid-clavicular 6 rib -
th th
Anterior axillary 7 rib 7 rib
th
Mid axillary 8 rib 8th rib
Posterior axillary 9th rib 9th rib
Scapular line 10th rib 10th rib
Paraspinal line Spinous process of the 11th Spinous process of the
thoracic vertebra 11th thoracic vertebra

Mobility lower edge of lungs:

Line Right Lung Left Lung

Mid – clavicular 1cm -
Mid – axillary 2cm 2cm
Scapular 2cm 2cm

On auscultation vesicular breathing is heard over symmetrical points of the

lung, adventitious sounds are absent. Bronchophony on symmetric parts of
the chest is identical.
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CARDIOVASCULAR SYSTEM

Visible arteries pulsations are absent. Vein pulse is negative. Cardiac

humpback and visible pulsation in the heart region are absent.
The apex beat is palpated in the 5th intercostal space, 1cm medially of
the left midclavicular line. It is restricted, low, medium strength.
Cat’s murmur was not determined. On auscultation the two heart
sounds are heard in all points. The sounds are rhythmic. Pulse is equal on
both arms. Pulse rate is about 90 beats per minute. Pulse is rhythmic,
moderate filling and diameter about 3mm.Temporal and carotid arteries are
well palpated and pulsation on both sides are equal. Arterial pressure is 120
mmHg systolic and 60 mmHg diastolic.

Relative cardiac dullness:

Right border- 1cm lateral from right border of sternum in the 4th
intercostal space.
Upper border - at the level of 3rd rid on parasternal line
Left border - 1cm medially from the left mid clavicle line at the level
th
of 5 inter costal space.
Absolute cardiac dullness:
Right border- along the left edge of the sternum
Upper border - on the inferior border of 4th rib on the level of
mid clavicle
Left border - 1 cm medially from relative cardiac dullness
Borders of vascular bundle:
Right border- on the right sternal line
Left border - on the left sternal line

On auscultation of the heart the 1st tone is louder than the 2nd tone in
apex and below the sternum. The 2nd tone is louder than the 1st tone on
pulmonary and aorta trunk points. On Botkin-Erb’s point both the tones are
equal. The tone is rhythmic and can be heard clearly.

DIGESTIVE SYSTEM

The tongue is of usual size, moist, coated with white layer. Teeth are
normal. Tonsils are absent.
Abdomen is of a regular form, symmetric. Abdominal wall
participates in breathing. Tympanic sound is heard all over parts of the
abdomen during percussion.

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 In superficial palpation abdomen is tender. Hernias and superficial
tumours are absent. Mendel’s and Schetkin-Blumberg symptoms are
negative.
In deep palpation the sigmoid colon is palpable in the left iliac region
as smooth cyclinder 2cm in diameter, painless, mobile, displaces on 1.5cm.
The cecum is palpable in the right iliac region as smooth, soft, painless
cylinder, 3cm in diameter, mobile.
Other parts of the intestine are not palpable.
On auscultation of the abdomen peristalsis movement of the intestine is
heard moderately. Greater curvature of stomach is determined as soft smooth
ridge 5cm above the navel. It is painless. Other parts of stomach are not
palpable.
Visible enlargement of the liver is absent. The liver is not palpable.
Upper border
of absolute hepatic dullness on the right midclavicular line is on the level of
6th rib, lower border is on the edge of the costal arch.
Gallbladder is not palpable. The symptoms of pressing and concussion
of gallbladder are negative. Tenderness in the points of gallbladder are not
determined.
Pancreas is not palpated. The morbidity in the tender points and
hyperesthesia in the zones of Zakharyin Head are absent.

URINARY SYSTEM

Urination of the patient is painless and visible pathology in the lumbar

region is absent. Kidneys are not palpated. Palpation of the kidneys region
are painless. Palpation in the course of the ureters is painless. Pasternatsky’s
symptom is negative on both sides.The urinary bladder is not palpable.

NERVOUS SYSTEM

The consciousness of the patient is clear. The patient’s manner of

speech is clear and correct. The patient is able to think in a logical and
rational manner.
Regarding the patient’s emotional sphere, the patient was not in a good
emotion and has derangement of sleep due to pain in the joints and
uncomfortable feelings.
Dizziness and noise in the ears of the patient are absent.
There are no muscular cramps on the extremities of the patient. The patient
does not have any numb sensations on his body. The extremities of the
patient are also able to move accordingly and are in-sync.
During inspection of the patient in Romberg’s pose, the patient is
steady. Any forms of paralyses and paresis is absent in the patient. The
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condition of the patient’s pupils is normal. The pupils constrict when a
bright light (with torch light) is shone through it.

ENDOCRINE SYSTEM

Changes of the eyes (exophthalmus or enophthalmus) are not

determined. Thyroid gland is not enlarged. Its isthmus is palpated as soft
painless band 1cm in diameter.
Ocular symptoms(Graefe’s,Kocher’s, Moebius’,Stelwag’s, Dalrympl’s) are
negative.

VIII. INITIAL DIAGNOSIS

Based on the complaints given:

 Pain and cramps and also discomfort in the epigastria region
 Pain in the lumbar region
 Severe diarrhea, water rice stool
 Nausea
 Vomiting
 Loss of appetite
 General weakness
 Dehydration
 Abdominal cramping
 Decrease urination
 Dry mouth
 Fever (38.0 degrees Celsius)

Patient can be initially diagnosed with acute gastroenteritis

( Toxicosis )

IX. DATA OF LABORATORY-CLINICAL AND SPECIAL

INVESTIGATION

Laboratory analysis

General analysis of blood

Analysis of urine
Biochemical test of blood
Blood glucose test
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 Functional Liver Test
Bacteriological test

Results of Analysis
Laboratory analysis results :

Analysis of Blood

Erythrocytes : 5.12 x 1012/L [norm: 4.5-5.0 x 1012/L]

Haemoglobin : 176.8g/L [norm: 135-180 g/L]
Color index : 1.03 [norm: 0.85-1.15]
Leucocytes : 4.1 x 109/L [norm: 4.0-9.0 x 109/L]
Stab : 31% [norm: 1-6%]
Segmented : 55% [norm: 47-72%]
Eosinophil : 3% [norm: 0.5-5%]
Basophil :0 [norm: 0-1%]
Lymphocytes : 15% [norm: 19-37%]
Monocytes : 3% [norm: 3-11%]
ESR : 3 mm/hr [norm: 2-10mm/h]

Urine Analysis

Colour : Straw Yellow

Protein : -
Specific gravity : 1.003
Glucose : -

Microscopy of urine sediment

Leucocyte : 3-4 in f.v.
Erythrocyte : -

Conclusion : No pathology.

Biochemical Test of Blood

Blood sugar : 4.5mmol/L [ normal : 3.33-5.55mmol/L]

Blood urea : 4.7mmol/L

Functinal Study of the Liver

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General bilirubin : 15.7 mmol/L
Direct bilirubin : 3.7 mmol/L
Indirect bilirubin : 8.8 mmol/L

Bacteriological Test

Coprocytogramm

Consistensy : Fluid
Colour : Greenish
Smell ; Putriefactious
Starcobilin : -
Gregerson test : -
Triboula test : -
Connective tissue digestive : -
Starch : -
Mucus : +
Luecocytes : 2- 3 in v.f
Erytrocytes ; -

Conclusions : Presence of many liquid. Characteristic for Enteric syndrome.

XI. DIFFERENTIAL DIAGNOSIS

Irritable Bowel Syndrome (IBS) can be confused with acute

gastroenteritis due to the similar symptoms such as, Pain and cramps and
also discomfort in the epigastria region ,diarrhea, with visible mucus
,Nausea, Vomiting, General weakness, Extreme exhaustion, Audible
rumbling of intestine, Abdominal cramping Bloated abdomen- (gas). But
the difference is acute gastroenteritis is based on toxication of food,
bacterial infections or viral infections. IBS occurs due to various
gastrointestinal tract complications..
Cholera can also be confused based on the symptoms given, but this
happens often without any pain, eyes shrunken with fingers wrinkled.
Campylobacter gastroenteritis – the symptoms include diarrhea but
bloody, abdominal cramp, pain, high fever, joints become swollen and red,
here liver and spleen are normally enlarged, there maybe meningitis and
endocarditis.

XIII. FINAL DIAGNOSIS AND ITS SUBSTANTIATION

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 Based on the patients complaints, initial diagnosis, differential
diagnosis, laboratory, instrumental and physical investigations, which are
the above,

The final diagnosis is:

Main disease : Acute gastroenteritis with moderate
degree of dehydration

Complications : none
Accompanying diseases : none

Substantiation :
 Pain and cramps and also discomfort in the epigastria region
 Pain in the lumbar region
 Severe diarrhea, water rice stool
 Nausea
 Vomiting
 Loss of appetite
 General weakness
 Dehydration
 Abdominal cramping
 Decrease urination
 Dry mouth
 Fever (39 degrees Celsius)

Gastroenteritis can be due to uncooked, half cooked, toxicated food, spoilt,

and contaminated food. For example, raw meat and left outside mayonnaise
from the fridge too long. Symptoms have been persistence for several days..

XIII. TREATMENT
Diet : No 4
Regime : Semi Bed Rest, Hospitalization, quarantined

Stomach and intestinal lavage

Medical Drugs

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 Etiotropic treatment :
Amikacin 1 tab 2 times a day IM 0.25 ampule.

Rehydration therapy
Rehydron 1.5-2 L
Intravenously : Sol. Ringer
Triosol
Serucal

Symptomatic therapy :
Multisorb 15.0 - 3 times a day

Prophylaxis

Patient is advised to wash all fresh fruits and vegetables before eating. All
meats are to be boiled and cooked fully and eggs should be fully boiled
(cooked) before eaten. Attention on personal hygiene : washing hands before
food intake, after usage of bathroom and etc.

Prognosis of disease

Prognosis of this patient is good for lifestyle, health and work. This disease
is often self limiting and often recover without any complications.

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