GENERAL DATA

AB, 5 y/o Male, from Camotes Cebu City,

Filipino, Roman Catholic
CHIEF COMPLAINT

Diarrhea
HISTORY OF PRESENT ILLNESS

➔ Onset: 8 hours PTC

◆ Approximately 15 episodes of fully soaked diapers
◆ Stool: Greenish-yellow, watery, foul smelling, mucoid, bloody
➔ No other associated symptoms
➔ Medications: Zinc sulfate 55mg/5ml, 5ml OD PO with Oresol
◆ No relief
HISTORY OF PRESENT ILLNESS

➔ 1 hour PTC, noted persistence of diarrhea with abdominal

pain
 PRENATAL HISTORY

➔ Mother is G2P1 (0011), 35 years old.

➔ Prenatal check-up was done at 24 weeks at their LHC seen by a midwife.
➔ Lab test: Urinalysis, CBC, STI screening and UTZ were unremarkable.
➔ She had multivitamins and Folic acid with good compliance.
➔ No maternal illnesses noted
POSTNATAL HISTORY

➔ Delivered via CS due to transverse lie

➔ Referred to a tertiary hospital attended by an OBGYNE

Apgar of 9,9
BS: 39 weeks
BW: 3000 grams.

➔ Discharged after 3 days with no other complications

FEEDING HISTORY

➔ Exclusively breastfed for 6 months and was mixed with

formula milk thereafter
➔ Weaning started at 6 months old mostly of rice porridge
and vegetables
IMMUNIZATION

➔ Immunization at birth were given

➔ Subsequent immunizations were taken at their LHC:
◆ DPT x 3, OPV x 3, Hep B x 3, MMR x 1
DEVELOPMENTAL HISTORY

❏ Distinguish between real and make-believe

❏ Speaks clearly in full sentences.
❏ Can print some letters or numbers.
❏ Hops and stands on one foot
❏ Swings and climbs
❏ Dress themselves, handle buttons and zippers, tie their shoes
❏ Develops sense of responsibility
FAMILY HISTORY

➔ MATERNAL: Hypertension and Cardiac problems

➔ PATERNAL: Diabetes
PERSONAL/SOCIAL HISTORY

➔ Live in a rented concrete housing

➔ Father: 41 y/o, works as a government employee, healthy
➔ Mother: Housewife
➔ Sibling: (1) 10 y/o, currently in 4th grade, healthy
➔ Water source:
◆ Drinking water from purified refilling water stations
◆ Past week, is from deep well boiled for 10 mins
PHYSICAL EXAM

➔ General: Awake, not in respiratory distress

➔ Vital Signs:
◆ HR: 122 Bpm
◆ RR: 25 bpm
◆ Temp: 36.6 C
◆ 02 sat: 100% at room air
PHYSICAL EXAM

Weight: 25kg
Height: 105cm
UAC: 11.5cm

➔ Skin: No pallor, No cyanosis, No jaundice, Good skin turgor

➔ HEENT: Normocephalic, non-sunken eyes and fontanels, dry
lips
and tongue, no alar flaring
➔ CL: CBS, ECE
PHYSICAL EXAM

➔ CVS: Adynamic precordium, distinct heart sounds, no murmurs

➔ Abdomen: Soft, Normoactive bowel sounds
(+) Tenderness in Hypogastric area
➔ GUT: Grossly male
➔ Extremities: SPP, CRT less than 2s
PRIMARY DIAGNOSIS

DYSENTERY
 Features Dysentery Acute diarrhea Persistent diarrhea

Bloody stool - - -

Foul Smell +/- +/- +/-

Varies/blood streaked
Color depends on blood - +
flow/location

Duration Variable 14 days< 14 days>

Mucus +/- - -
 Features Viral Gastroenteritis Appendicitis Acute Cholecystitis

Rovsing Sign - + -

Nausea + + +

Vomiting + + +

Abdominal
- +/- +
Distension

Lack of apppetite +/- + -

Working diagnosis
Dysentery
Diagnostics (N)
● Culture of both stool and rectal swab
● Film Array Gastrointestinal Panel and Eurofins Diatherix Panel
● conventional polymerase chain reaction (PCR_
● Serotyping
Diagnostics (N)
● Culture of both stool and rectal swab
● Film Array Gastrointestinal Panel and Eurofins Diatherix Panel
● conventional polymerase chain reaction (PCR_
● Serotyping
Diagnostics (P)
● abdominal pain
● fever
● convulsions
● lethargy
● dehydration (see section 5.2, p. 127)
● rectal prolapse.
Diagnostics (P)
● abdominal pain
● fever
● convulsions
● lethargy
● dehydration (see section 5.2, p. 127)
● rectal prolapse.
Treatment and Management
Most children can be treated at home.

Admit to hospital:
● young infants (< 2 months old)severely ill children, who look
lethargic,have abdominal distension and tenderness or convulsion
● children with any another condition requiring hospital treatment.
Give an oral antibiotic (for 5 days) to which most local strains of Shigella are
sensitive.
● Give ciprofloxacin at 15 mg/kg twice a day for 3 days if antibiotic
sensitivityis unknown. If local antimicrobial sensitivity is known, follow
local guidelines.
● Give ceftriaxone IV or IM at 50–80 mg/kg per day for 3 days to severely
ill children or as second-line treatment.
● Give zinc supplements as for children with watery diarrhoea.
Follow-up
● Follow up children after 2 days, and look for signs of improvement, such
as no fever, fewer stools with less blood, improved appetite.
 ● Infants and young children
● Severely malnourished children
Supportive care
● Supportive care includes the prevention or correction of dehydration and
continued feeding. For guidelines on supportive care of severe acutely
malnourished children with bloody diarrhoea, see also Chapter 7 (p. 197).
● Never give drugs for symptomatic relief of abdominal or rectal pain or to
reduce the frequency of stools, as these drugs can increase the severity of
the illness.

● Treatment of dehydration
● Nutritional management
Complications:
● Dehydration
● Potassium depletion
● High fever
● Rectal prolapse
● Convulsions
● Haemolytic yremic syndrome
● Toxic megacolon
Enteroinvasive E.coli (EIEC)
● Infections present either with watery diarrhea or a dysentery syndrome
with blood, mucus, and leukocytes in the stools, as well as fever, systemic
toxicity, crampy abdominal pain, tenesmus, and urgency
● The illness resembles bacillary dysentery because EIEC shares virulence
genes with Shigella sp.
● Sequencing of multiple housekeeping genes inidcates that EEC is more
related to Shigella than to noninvase E.coli.
● EIEC diarrhea occurs mostly in outbreaks; however, endemic disease
occurs in developingh countries.
Treatment
● The cornerstone of management is appropriate fluid and electrolyte therapy. It
should be include oral replacement and maintenance with rehydration
solutions such as those specified by the WHO.
● Pedialyte and other readily available oral rehydration solutions are acceptable
alternatives. After refeeding, continued supplementation with oral rehydration
fluids is appropriate to prevent recurrence of dehydration. Early refeeding
(within 6-8 hr of initiating rehydration) with breast milk or infant formula or
solid foods should be encouraged.
Prevention of illness
● In the developing world, prevention of disease caused by pediatric
diarrheagenic E.coli is probably best done by maintaining prolonged
breastfeeding, paying careful attention to personal hygiene, and following
proper food and water handling procedures. Protective immunity against
diarrheagenic E.coli remains an active area of research, and no vaccines are
available for clinical use in children.