ADMISSION

CONFERENCE
CLINICAL HISTORY
Informant: Mother
Reliability: 65%
General Data
● AV
● 1 year and 2 months
● Born on December 15, 2015
● Admitted for the 1st time at our institution on February 27,
2017
 CHIEF COMPLAINT

Decreased appetite for 6 days

History of Present Illness
● 5 days PTA
○ Decreased appetite
■ 4 bottles (210cc each) + 6 tsp of rice w/ soup to 3 bottles (210cc
each) w/ no solid food
○ Intermittent fever (Tmax 39C)
■ Paracetamol 120mg/5ml, 2.5ml (TD: 8.3mg/kg/dose)
○ Good activity
○ 1 episode of pasty stool (Bristol type 6)
○ 5 diaper changes, fully soaked
○ (-) cough, colds, vomiting
○ No consult was done
History of Present Illness
● 4 days PTA
○ Decreased appetite
○ Good activity
○ 1 episode of pasty stool (Bristol type 5)
○ 4 diaper changes, moderately soaked
○ (-) fever, cough, colds, vomiting
○ No medications given
○ No consult was done
History of Present Illness
● 3 days PTA
○ Decreased appetite and decreased activity
○ 2 episodes of non-projectile vomiting
○ 3 episodes of bowel movement, watery based (Bristol type 7)
○ Give ORS - not tolerated
○ (-) fever, cough, colds
○ Sought consult - assessed as Herpangina with associated Diarrhea
○ ORT done and tolerated
○ Advised CBC, fecalysis, urinalysis
○ Given ORS and Zinc Sulfate 10mg/ml, 2 ml OD (TD:20mg/day)
○ At home, prefers milk over ORS, still with 4-5 episodes of watery based
bowel movement
History of Present Illness
● 2 days PTA
○ 2 episodes of vomiting, non-bilious, non-projectile
○ 5 episodes of scanty watery based bowel movement (Bristol type 7)
○ Decreased activity and appetite
○ Sunken eyeballs
○ Raised erythematous non-pruritic rash on feet
○ No medications given
○ No consult done
History of Present Illness
● 1 day PTA
○ 5 episodes of scanty watery based stool, foamy (Bristol type 7)
○ Decreased appetite
■ 3 bottles of 210cc w/ no solid food to 3 bottles of 105 cc
○ Decreased activity
○ Raised erythematous non-pruritic rashes on legs and thighs
○ No medications taken
○ No consult done
History of Present Illness
● Few hours PTA
○ Consult was done
○ ORT as outpatient - not tolerated
○ Advised admission -> admitted
Past Medical History
● No history of mumps, chickenpox or measles
● (+) Primary Pulmonary Tuberculosis - 4th month ongoing treatment
● Approximately 6 times of colds per year
● No previous history of surgery, accidents or blood transfusion
● No history of Bronchial Asthma
● No history of heart, liver, kidney diseases or other heredofamilial diseases
● No known allergies to food and drugs
 Immunization History
Vaccines Dose Place Given

BCG 1 Brgy. Health Center

OPV 3 Brgy. Health Center

Hepa B 3 Brgy. Health Center

DPT 3 Brgy. Health Center

MMR 1 Brgy. Health Center

Measles 1 Brgy. Health Center

PCV 1 Brgy. Health Center

 Developmental History

Age Gross Fine Language Personal/ Social

2 months Brings hand to Coos Smiles

mouth responsively

3 months No head lag Smiles

responsively

4 months Turns to prone Babbles

 Developmental History

Age Gross Fine Language Personal/ Social

5 months Rolls over Reaches for Laughs and

objects squeals

6 months Sits with support Holds bottle Claps

8 months Sits alone Transfers object Waves goodbye

hand to hand and enjoys
mirror
 Developmental History

Age Gross Fine Language Personal/ Social

9 months Stands with Handles spoon

support

10 months Walks with Bangs two Plays peek-a-boo

support blocks together

12 months Walks alone Plays with blocks Can say mama

(4 pcs) and dada
Nutritional History
● Purely breastfed from birth to 2 months
● Mixed feeding at 2 months old
○ S26 (unrecalled dilution)
○ 4-5 bottles per day, 210 cc each
● Complementary feeding at 6 months old
● 8 months old to present
○ Formula milk shifted to Bonakid
○ 4 bottles per day
○ Eats 6 Tbsp of rice with soup every mealtime
Family History
● Father: 30 y/o, call center agent, history of allergy to dust
● Mother: 26 y/o, virtual assistant, current history of watery based stools for 4 days, no consult done,
diagnosed with PTB (Nov 2016) on 4th month of treatment
● Siblings:
○ 4 y/o sister: currently on treatment for UTI with unrecalled antibacterial medication, history
of Bronchial asthma-controlled, allergy to dust
○ Twin sister: with history of primary pulmonary tuberculosis on 4th month of treatment;
with current history of diarrhea with ongoing ORT at home
● (+) heart disease, maternal side
● No known history of heredofamilial diseases such as hypertension, arthritis, liver diseases, and
malignancy
Personal History
● Lives in a 2-storey house, non-crowded neighborhood
● Primary caregiver: mother
● Sleeps 8 hours at night with 1-2 hour naps in the afternoon
● Main water source: tap water
● Drinking water: distilled
● Garbage not segregated, collected twice per week
 Physical
Examination
Physical Examination
General Survey: awake, fretful, not in cardiorespiratory distress, with some signs of
moderate dehydration
Vital Signs:

HR: 116 bpm

RR: 34 cpm
Temp: 36.8 C
Physical Examination

Anthropometric measurements

Weight: 7.2 kg
Head circumference: 46 cm
Chest circumference: 47 cm
Abdominal circumference: 44 cm
Wt: 7.2 kg
Age: 1 yr 2 mos
Length: 70 cm
Age: 1 yr 2 mos
Weight: 7.2 kg
Length: 70 cm
HC: 46 cm
Age: 1 yr 2 mos
Physical Examination
HEENT: sunken eyeballs, pink palpebral conjunctivae, white sclerae, patent ear canals,
patent nostrils, dry lips, moist buccal mucosa, hyperemic pharyngeal wall with multiple
ulcers with erythematous base on posterior pharyngeal wall
NECK: supple neck, no palpable cervical lymph nodes
LUNGS: symmetrical chest expansion, no retractions, clear breath sound, good air entry
HEART: adynamic precordium, normal rate, regular rhythm, no murmurs
Physical Examination
ABDOMEN: slightly globular, soft, normoactive bowel sounds, no tenderness, no
palpable masses, no lesions
EXTREMITIES: no gross deformities, full and equal pulses, with CRT <2 seconds
SKIN: erythematous perianal rash, maculopapular rash with erythematous base on
feet, legs, thighs, abdomen
Neurologic Examination
Cerebrum: Awake and fretful
Cerebellum: no nystagmus, no ataxia
Cranial nerves:
I: N/A
II: 2-3 mm pupils equally reactive to light
III, IV, VI: Intact extraocular muscles
V: Good sucking, can clench teeth
VII: No facial asymmetry
VIII: Intact gross hearing
Neurologic Examination
IX and X: Can swallow meals
XI: Can turn head from side to side
XII: Tongue at midline
Motor Function: Can move all extremities
Sensory Function: Withdraws to pain
Deep Tendon reflex: +2
Reflexes: No primitive reflexes, (-) Babinski sign
Signs of Meningeal Reflexes: No nuchal rigidity, no Kernig sign, no Brudzinski sign
Salient Features
● 1 year and 2 months
● CC: Decreased appetite for 6 days
● Intermittent fever Tmax: 39 C (5 days PTA)
● Decreased activity
● Non-projectile vomiting of previously ingested milk
● Watery based bowel movements (bristol type 7) sour smelling, non frothy
Salient Features
● Moderate dehydration, tachycardic, tachypneic
● Sunken eyeballs, dry lips
● Hyperemic pharyngeal walls with multiple ulcers with erythematous base on
posterior pharyngeal walls
● Erythematous perianal rash
● Maculopapular rash with erythematous base on feet, legs, thighs, abdomen
 INITIAL IMPRESSION
Hand, Foot, & Mouth disease;
Acute gastroenteritis, probably viral;
Moderate dehydration;
t/c Lactose intolerance, secondary;
Diaper rash, secondary;
t/c Urinary tract infection;
Primary Pulmonary Tuberculosis
=
Differential Diagnosis
● Decreased appetite

HAND, FOOT, AND MOUTH DISEASE

RULE IN RULE OUT
● Multiple ulcers with erythematous
base on posterior pharyngeal wall ● Cannot be totally ruled
● Hyperemic pharyngeal walls out
● Decreased appetite
● raised erythematous non pruritic rash
appeared on the feet, legs, and thigh,
and abdomen
● Intermittent Fever
HERPANGINA
RULE IN RULE OUT
● multiple ulcers with erythematous ● raised erythematous non
base on posterior pharyngeal wall pruritic rash appeared on the
● Decreased appetite feet, legs, and thigh
● Intermittent Fever
ACUTE GASTROENTERITIS, VIRAL
RULE IN RULE OUT
● Loose stools for 3 days ● Cannot be totally ruled
● Intermittent fever (Tmax 39 C) out
● Non-projectile vomiting
● Decreased appetite and activity
● Family history of diarrhea
● No Rotavirus vaccine
ACUTE GASTROENTERITIS, BACTERIAL
RULE IN RULE OUT
● Loose stools for 3 days ● Non bloody stools
● Non projectile of vomiting ● Fever >40C
● Decreased appetite and activity ● Cannot be totally ruled out
LACTOSE INTOLERANCE
RULE IN RULE OUT
● Loose stools for 3 days ● Cannot be totally ruled out
● Sour-smelling stool
● Non projectile vomiting of
previously ingested milk
● Erythematous perianal area
LABORATORY
EXAMINATION
RESULTS
Serum Electrolytes
Result Normal Value

Na+ 136 134-143

K+ 3.94 3.3-4.6

Cl- 100 98-106

Ionized Ca++ 1.36 1.12-1.23

Complete Blood Count
Result Normal Value

Hgb 118 g/L 105-140

Hct 0.347 g/L 0.32-0.42
MCV 79.8 72-88
MCHC 340 320-360
MCH 27.1 24-30
Complete Blood Count
Result Normal Value

RDW-CV 13.4 11-16

RDW-SD 38.7 35-56
PLT ct 231 150-400
MPV 10.8 6.5-12
PDW 11.9 9-17
Complete Blood Count
Result Normal Value

WBC ct 8.82 6.0-14.0

Neutrophils 0.398 0.54-0.62
Lymphocytes 0.494 0.25-0.33
Monocytes 0.093 0.03-0.07
Eosinophils 0.014 0.01-0.03
Basophils 0.001 0-0.0075
 MAIN DIAGNOSIS

Hand, Foot, and Mouth Disease;

Acute Gastroenteritis, probably viral;
Moderate Dehydration;
Lactose intolerance, secondary;
Diaper rash, secondary;
Primary Pulmonary Tuberculosis
 CASE
DISCUSSION
ACUTE GASTROENTERITIS
● Denotes infection of the Gastrointestinal tract caused by
Bacterial, Viral, or Parasitic pathogens.
● Most common manifestations are Diarrhea and Vomiting.
Can also be associated with abdominal pain and fever.
● Diarrhea: >/= 3 loose stools in 24 hrs
○ Acute Diarrhea (less than 14 days)
RISK FACTORS
● Age
● Inadequate hygiene, Sanitation, Clean drinking water
● Lack of exclusive and predominant breastfeeding
● Immunodeficiency
● Malnutrition
COMPLICATIONS
● Dehydration
● Electrolyte imbalance/ Acid Base derangements
● Secondary infections
● Malnutrition
● Micronutrient deficiencies
LACTOSE INTOLERANCE
● Unable to digest Lactose Ingestion causes symptoms
○ Diarrhea
○ Vomiting
○ Abdominal pain
○ Bloating
○ Excessive flatus
● Secondary to Gastroenteritis
LACTOSE INTOLERANCE
● Usually transient, improving with mucosal healing
● Lactase-treated dairy products or oral lactase
supplementation, limitation of lactose-containing foods,
dairy elimination
HAND, FOOT, AND MOUTH DISEASE
● distinctive rash syndrome, most frequently caused by
○ coxsackievirus A16
○ enterovirus 71
○ coxsackie A viruses 5, 6, 7, 9, and 10
○ coxsackie B viruses 2 and 5
○ echoviruses
HAND, FOOT, AND MOUTH DISEASE
Transmission
● fecal-oral route or via contact with skin lesions and oral secretions
○ Blisters
○ Saliva
○ Airborne droplets
○ Feces
HAND, FOOT, AND MOUTH DISEASE
● inflamed oropharynx
● vesicles on the tongue, buccal
mucosa, posterior pharynx,
palate, gingiva, and/or lips
● may ulcerate, leaving 4-8 mm
shallow lesions with
surrounding erythema
HAND, FOOT, AND MOUTH DISEASE
● Maculopapular, vesicular, and/or pustular
lesions
● hands and fingers, feet, and buttocks and
groin
● hands and feet
● Vesicles resolve in about 1 week
MANAGEMENT
 PLAN
● Admit patient to pedia ward
● Secure consent for admission and management
● Place on NPO for four hours, then may resume feeding if no recurrence of vomiting
● Shift to Lactose Free Milk
● Hook to D5LR to run at a rate for 45 cc/hr for 8 hours
● Request for Fecalysis, Serum Electrolytes, Urinalysis, CBC
● Give Zinc Sulfate drops 2ml once a day
● Apply Zinc Oxide to the diaper area after every diaper change
● Monitor Vital signs every 4 hours and record
● Monitor intake and output every shift and record
● Watch out for persistence of vomiting and loose stools
● Refer accordingly
DIET
● Place on NPO for four hours, then may resume feeding if no
recurrence of vomiting
● Hook to D5LR to run at a rate for 45 cc/hr for 8 hours
● Shift to Lactose Free Milk
DIAGNOSTICS
- Complete blood count
- Serum electrolytes
- Urinalysis
- Fecalysis
DRUGS
● Give Paracetamol syrup 250mg/ml given 1.5 ml every 6 hrs as needed
(TD: 10.42 mg/kg/dose)
● Zinc sulfate drops: 2ml once a day for 14 days
● Zinc oxide topical: Apply onto affected area as often as needed at each
diaper change
DISPOSITION
● Keep child warm and dry
● Update Immunization
● Educate parents on proper food handling
● Educate on clean drinking water practices
● Educate on hygiene with proper handwashing, proper disposal of wastes, and
handling of bottle sterilization
● Educate on general skin care measures (Diaper changing)
● Vitamin A supplementation
● Probiotics
 THANK YOU!

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