SCENARIO-BASED

LEARNING
GIT Emergencies :

Diarrhoea & Vomitting

Supervisor : Dr Azim Ab Manap

Prepared by : Iffah Zulaika Bt Ika Rahardjo

Mohd Iqbal Hakimi Bin Mohd Sah
Syafiq Bin Sofiyan

Bachelor of Science in Emergency Medicine with Honours

CASE SCENARIO
HOPI :
60 years old man with no medical illness brought in to Emergency Department (ED) with generalised
body weakness for 2 days. Further questioning revealed that the patient had vomiting and diarrhoea
about 6 times per day for 5 days.

On arrival to ED : appeared lethargic with

dry mucous membrane.

Vital Sign :
Blood Pressure : 90/55 mmHg
Heart Rate : 125 beats/minute
Respiratory rate : 18 breaths/minute
SPO2 : 97% under room air
LIST DOWN YOUR DIFFERENTIAL
DIAGNOSIS AND FURTHER HISTORY
TO DIFFERENTIATE EACH
DIAGNOSIS
BY : IQBAL HAKIMI
 • In most cases, can be diagnosed as mild gastroenteritis based on the symptoms,
history of exposure to spoiled food, impure water or someone with diarrhoea, and
the results based on the physical examination. 10

• uncomplicated gastroenteritis last one to seven days. ( depends on

personal/person body resistance and resilience ) 10
Acute • INFECTIOUS CAUSES of acute diarrhoea include viruses, bacteria, and, less often,
Gastroenteritis parasites. NON-INFECTIOUS CAUSES include medication adverse effects, acute
abdominal processes, gastroenterology disease, and endocrine disease. 11 12

• acute diarrhoea.pdf 13

 
 
 
 

10. https://www.health.harvard.edu/a_to_z/gastroenteritis-in-adults

11. Aranda-Michel J, Giannella RA. Acute diarrhea: a practical review.  Am J Med. 1999;106(6):670–676.

12. Turgeon DK, Fritsche TR. Laboratory approaches to infectious diarrhea.  Gastroenterol Clin North Am.
2001;30(3):693–707.

13. WENDY BARR, MD, MPH, MSCE, and ANDREW SMITH, MD, Lawrence Family Medicine Residency,
Lawrence, Massachusetts Am Fam Physician. Acute Diarrhoea in Adult 2014 Feb 1;89(3):180-189.
 • Which symptom started first ?

• Are you living in any dengue prone area ? 5 6

• Any of family member and neighbourhood had been diagnosed

with dengue fever recently ? 5 6
Dengue • Are there any skin rashes and body ache? 5 6
Fever
 
• There is any gum/ nose bleeding ( bleeding tendency – mucosal ). 5
 
 
Lab diagnosis :
Dengue Serology (Ns1 and IgG,IgM), FBC
 
 
 

5. Ministry of Health Malaysia, CPG of management of dengue infection in adults, third edition 2015,
MOH/P/PAK/302.15(GU)

6. World Health Organization. Dengue Guidelines for Diagnosis, Treatment, Prevention and Control - New Edition 2009.
WHO: Geneva; 2009
 • Work in or travel to areas where typhoid fever is established (endemic). 3 4

• Work as a clinical microbiologist handling Salmonella typhi bacteria. 34

• Have close contact with someone who is infected or has recently been infected with
typhoid fever. 3 4

• Drink water contaminated by sewage that contains Salmonella typhi. 3 4

Typhoid
Fever • Have you ever eat any raw food and vegetable. 3 4
 
 
Lab diagnosis :
Salmonella species ( eg : Entritica Serotype Thypi), Infectious diarrhoea
 

3. Wain J, et al. Typhoid fever. The Lancet. 2015;385:1136.

4. Hohmann EL. Epidemiology, microbiology, clinical manifestations, and diagnosis of typhoid fever.
http://www.uptodate.com/home. Accessed June 10, 2015.
   • Do you take any Lactose base food/drink today ? 9

• Any upper abdominal pain that radiates into the back; it may be

aggravated by eating, especially foods high in fat. 8
Malabsorption  
Diagnostic Investigation :
Pancreatitis Pancreatic  Function Test to find out if the pancreas is making the right
  amounts of digestive enzymes, ultrasound, MRI
 
 
 
 

8. https://www.webmd.com/digestive-disorders/digestive-diseases-pancreatitis#1

9. https://accessmedicine.mhmedical.com/content.aspx?bookid=1088&sectionid=61698057, McGraw Hill

access medicine, acute diarrhea
 1. There is any visible blood in diarrhoea ? 7
 
 

Lab diagnosis :
Dysentery  
Shigella dysenteriae , E.Coli 0157, Entamoeba histolytica etc.
 
 

7. Ministry of Health Malaysia, Case definitions for infectious diseases in Malaysia,

second edition 2006 : Dysentery (ICD 10 : A09 ), MOH/K/EPI/32.02(HB)
 • Constant mid-abdominal pain that later shifts to right lower quadrant. Usually
worse on movement.1

• The diagnostic sequence of colicky central abdominal pain followed by vomiting

with migration of the pain to the right iliac fossa was first described by Murphy but
may only be present in 50% of patients. 2 

• Bowel sounds may be reduced, particularly on the right side compared with on the
left. 1
Perforated
Appendicitis • Profuse vomiting may indicate development of generalised peritonitis after
perforation but is rarely a major feature in simple appendicitis. 2

P/E :
McBurney's sign, psoas sign, Rovsing's sign, obturator sign Pregnancy test—
to exclude pregnancy (ectopy
 
 
 
 
 

1. Hardin DM. Acute appendicitis: review and update. Am Fam Physician. 1999;60:2027-2034.

2. Murphy J. Two thousand operations for appendicitis, with deductions from his personal
experience. Am J Med Sci 1904;128: 187-211
Discuss Clinical
Approach Of Body
Weakness
BY : IFFAH ZULAIKHA
 Intracerebral Cancer ?
Dehydration ?
Haemorrhage ?
Dehydration?
Myasthenia gravis ? Hypoglycemia?

Ischemic
Anemia ? stroke ?

Myositis ? Hypothyroidism ? Infection ?

 DEFINITION

Weakness is the inability to perform a desired movement with normal

force because of decrease in strength or power
 SIGN AND SYMPTOMS
• Pain • Inability to concentrate
• Extreme exhaustion • Confusion
• Weakness • Irritability
• Lack of energy • Depression
• Headache • Visual disturbances
• Low grade fever  • Sleep disturbances
• Sore throat • Chronic immobility
• Muscle & joint pains that radiate
without swelling or redness
• Painful menstrual periods
 CAUSES

1. Infection HPT,DM, IHD, stroke etc

Flu, fever etc 1. Social factor
2. Medication  Alcohol consumer, drug addict,
Chemotheraphy , anti anxiety sedentary lifestyle
drugs, vitamin overdose etc 2. Age related
3. Physical 3. Gender
Overexercise, obese patient etc
4. Underlying disease
 EXAMINATION
• Babinski response Vitamin B12 Level
• Blood tests : Lyme Titer
Complete Blood Count (CBC) • Imaging tests :
Glucose Level Xray
Sedimentation Rate Ultrasound
Serum Protein Electrophoresis CT scan
Antinuclear Antibody Levels MRI scan
Vdrl/Rpr Electromyography (if necessary)
 CLINICAL
APPROACH
 TAKE HOME MESSAGE
The 1st important step in an algorithmic approach is to determine whether the
weakness is unilateral (asymmetric) or bilateral (symmetric) and to look closely for
signs and symptoms of central neurologic involvement. Eg ;
• History taking
• Pain score
• Spatial distribution of weakness
• Family history
• Temporal characteristics of onset and progression of the weakness
Finally, narrowing down the cause of the weakness requires considering the list of
possible conditions that can produce the type of weakness being manifested by the
patient.
List the parameters included in
assessing the patient’s
hydration status
BY : SYAFIQ SOFIYAN
ASSESMENT METHOD

PHYSICAL ASSESMENT
LABORATORY TEST
 Physical Assesment
Aim : to evaluate the severity of dehydration and the cause.

Methods of assessment

History:
Stooling and vomiting frequency,
stool consistency,
stool volume ,
the presence of mucus and blood in the stools,
urine output,
weight change,
presence of pyrexia,
infectious
disease contact.
Physical Assesment
Clinical Examination:
Vital signs including
conscious level
weight change,
blood pressure,
temperature,
pulse rate ,
respiratory rate;
WHAT ARE THE SIGNS
OF SHOCK?
 Tachycardia

 Weak peripheral pulses

 delayed capillary refill time > 2 seconds

 cold peripheries

 depressed mental state

 with or without hypotension

Ref : Malaysia Pediatric
protocol 4th edition
DEGREE
HYDRATION STATUS
CLINICAL SYMPTOMS
3-5% dehydration warm , normal capillary refill in the extremities normal or slightly sunken eyes dry mucous membranes
(Mild) thirst, oliguria. flat anterior fontanelle normal blood pressure, pulse volume, heart rate

6 - 9% dehydration very obvious loss of skin tone and tissue turgor delayed capillary refill dry mucous membrane and
(Moderate) sunken eyes marked thirst and oliguria ( < 1 ml/kg/h) often some restlessness and apathy sunken
fontanelle normal blood pressure but pulse volume may be decreased heart rate increased

10% and more all the foregoing, plus peripheral vaso-constriction (cool, mottled peripheries) thready or absent pulse,
dehydration tachycardia hypotension, cyanosis, and sometimes hyperpyrexia extremely thirsty or the child may be
(Severe) too ill to ask for fluids anuria, acidotic breathing reduced conscious level or comatose
EXAMPLE ?
ISOTONIC
Cause : vomiting & diarrhea, excessive sweating
e.g : Gastroenteritis

HYPERTONIC
Cause : polyuria, reduce water intake, drinking seawater
for survival
e.g: Loop Diuretics consumptions

HYPOTONIC
Cause : diuretics, renal tubular acidosis
e.g: Rt sided heart failure, nephrotic syndrome
 Laboratory Test
Blood Parameters
• Full blood count
• Urea and electrolytes (if more than 5% dehydration) –
 Hyponatremia
 Hypokalemia
 metabolic acidosis

Stool Parameters - (To identify presumptive enteric pathogen)

• Stool microscopy
• bacteriology (culture) to rule out bacteria infection as a cause of diarrhea
• viral studies
 LABORATORY TEST
Urine Parameters
• Urine specific gravity
Compare density of urine to density of water
How well your kidneys are compensating
Specific density of water would be 1.000
High urine specific gravity indicates extra substance in urine (e.g glucose, protein,
bilirubin, rbc, crystals, bacteria)
• Urine osmolality
Measure the number of dissolved particles per unit of water in urine
More accurate than specific gravity
Normal 24-hr urine osmolality avg = 500-800 mOsm/kg
• Urine colour
clear urine indicates well hydrated
Darker urine indicates dehydration
References
https://emedicine.medscape.com/article/2088250-overview

Kavouras, S. A. (2002). Assessing hydration status. Current Opinion in Clinical Nutrition & Metabolic Care, 5(5), 519-524.

Liebelt, E. L. (1998). Clinical and laboratory evaluation and management of children with vomiting, diarrhea, and
dehydration. Current opinion in pediatrics, 10(5), 461-469.

Hardin DM. Acute appendicitis: review and update. Am Fam Physician. 1999;60:2027-2034.

Murphy J. Two thousand operations for appendicitis, with deductions from his personal experience. Am J Med
Sci 1904;128: 187-211

Wain J, et al. Typhoid fever. The Lancet. 2015;385:1136.

Hohmann EL. Epidemiology, microbiology, clinical manifestations, and diagnosis of typhoid fever.
http://www.uptodate.com/home. Accessed June 10, 2015.

Ministry of Health Malaysia, CPG of management of dengue infection in adults, third edition 2015, MOH/P/PAK/302.15(GU)

World Health Organization. Dengue Guidelines for Diagnosis, Treatment, Prevention and Control - New Edition 2009. WHO:
Geneva; 2009

Ministry of Health Malaysia, Case definitions for infectious diseases in Malaysia, second edition 2006 : Dysentery
(ICD 10 : A09 ), MOH/K/EPI/32.02(HB)

https://www.webmd.com/digestive-disorders/digestive-diseases-pancreatitis#1

https://accessmedicine.mhmedical.com/content.aspx?bookid=1088&sectionid=61698057, McGraw Hill access medicine, acute

diarrhoea

Aranda-Michel J, Giannella RA. Acute diarrhea: a practical review.  Am J Med. 1999;106(6):670–676.

Turgeon DK, Fritsche TR. Laboratory approaches to infectious diarrhea.  Gastroenterol Clin North Am. 2001;30(3):693–707.

WENDY BARR, MD, MPH, MSCE, and ANDREW SMITH, MD, Lawrence Family Medicine Residency, Lawrence, Massachusetts
Am Fam Physician. Acute Diarrhoea in Adult 2014 Feb 1;89(3):180-189.
ANY QUESTIONS?