roxie amoeba

8/12/2019 Roxie Amoeba

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ADMITTING

CONFERENC

JI MEDRIANO, ROXANNE F.

Pediatric junior intern


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MCG

1 year and 3 months old

Female

Infant

Roman catholic

March 03, 2013 BGH-Baguio City

#145 Poliwes, Kennon Road, Baguio City.

admitted for the 1sttime in this institution, SLU-HSH on July 1, 2014.

The informant is the mother with a percentage reliability of 92%.


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Cough, fever, diarrhea, convulsion


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8 days prior to admission (+) non-productive cough, with associated colds, nasal secret

was characterized as clear and watery no associated fever, vomiting, diarrhea, no nasal congestion,

signs of difficulty of breathing such as fast breathing, chestindrawing and alar flaring

good oral intake and sleep was uninterrupted. According to her mother, maybe the patient had acquired it f

her grandmother since the grandmother had cough and coldthat time.

no medications given. No consultations done.


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7 days prior to the admission

increase in the frequency of the patients coughing episod

and it became productive- not able to expectorate the

phlegm.

The colds with clear and watery secretion also persisted.

Post-tussive vomiting 2x: vomitus was characterized as whit

in color which is probably the ingested milk with phlegm.

(+) fever with a Tmax of 38.5 degree Celsius per axillary, an

nasal congestion


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(+) signs of difficulty of breathing such as fast breathinand alar flaring.

(+) irritability as manifested by incessant crying andinterrupted sleep,

decrease in appetite noted.

Consult: meds given :Amoxicillin 0.8 ml TID, Carbocyste(Solmux) 1 ml TID, Phenylpropanolamine HCl (Disudrin)ml TID, and Paracetamol 100/1 1ml every 4 hours forfever.


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1 day prior to the admission

(+) diarrhea: 4x--- stool was described to be yellowish in coand watery, non- bloody, non- mucoid and foul smelling,

amounting to approximately 30-40 cc per episode

cough and colds persisted despite completion of theantibiotics.

(-)vomiting, nasal congestion, signs of difficulty of breathingsuch as fast breathing, chest indrawing and alar flaring.

(+) increasing irritability as manifested by incessant crying a

interrupted sleep decrease in appetite

(-) medications were given

tepid sponge bath was done by the grandmother whichoffered temporary lysis of fever.


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Few hours PTA, the fever, cough and colds and diarrhea persisted. One episode of seizure was noted which was characterized as

upward rolling of the eyeballs and stiffening and jerking of the lelasting about less than 5 minutes.

first time that the patient had seizure.

(-) episodes of vomiting (+) poor oral intake, disturbed sleep, and became more irritable. No medications were given and no other relief measures were d

to address the problem. Consultpresent admission.


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PAST PERSONAL HISTORY


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BIRTH HISTORY


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PRENATAL HISTORY 26 years old, G1P0 cognizant of pregnancy at 6 weeks AOG pregnancy test done

Prenatal care was instituted at 6 weeks AOG by an obstetrician

Total: 7 prenatal checkups done regularly

ultrasound revealing a singleton, live baby girl, pregnancy in utecephalic in presentation

No history of exposure to viral exanthematous disease, radiation,alcohol and other drugs

(+) certain exposure to cigarette smoke since some of her friends

No maternal illness during the course of pregnancy such as UTI orHypertension.


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NATAL HISTORY Term via NSD

Baguio General Hospital

Birth weight: 2.1 kg

birth length and other anthropometric measurements wereunrecalled

Upon birth: (+) pink body with good cry and active limbmovements

No congenital malformations

Apgar score and Ballard score were unrecalled.


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NEONATAL HISTORY

Breastfed with good suck,

Hospital stay: 3 days

Newborn screening: normal

Hearing test: passed for both ears.


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FEEDING HISTORY

Breastfed with good suck per demand up to 6 months

Complementary milk was given at 6 months withNestogen at a dilution of 3scoops in 120 mL, consuminabout 20 mL per feeding, with a frequency of about 6bottles of 60 mL milk in a day

No episodes of feeding intolerance like loose bowelmovement noted


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Semi-solid foods like rice, mashed vegetable (potato, squawere introduced at 6 months of age. At present, sample diincludes:

Multivitamins of Appebon at 2.5ml and Ascorbic Acid 2.5 msuggested by a friend, were started when patient was 5months old and is given once a day.

Breakfast Cerelac/ Mashed rice + milk 60 ml4-5 spoonfuls

Lunch Cerelac/ Mashed rice + milk 60 ml

4-5 spoonfulsDinner Cerelac/ Mashed rice + milk 60 ml

4-5 spoonfulsSnacks 2 pcs of bread


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GROWTH AND DEVELOPMENTAL HISTO

PHYSICAL GROWTH

BIRTH WEIGHT = 2.1kg PRESENT WEIGHT = 9kg

BIRTH LENGTH = unrecalled PRESENT LENGTH = 75 cm

Head Circumference = unrecalled Arm Circumference = unrecalle

Chest Circumference = unrecalled


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DEVELOPMENTAL MILESTONES

Gross Motor: stands alone, walks with assistance

Fine Motor: makes line with crayon

Language: can say mama/ dada

Social: shy with strangers, feeds self

Prior to admission, the patient is playful and active.Developmental milestones at par for age.


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SOCIAL DEVELOPMENT

Sleeps: 8:00 pm at night

Wakes: 6:00 or 6:30 am

Takes several naps during the day

She is not-toilet- trained yet

interacts with family and peers without disciplineproblems.


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IMMUNIZATIONS

The childs immunization record is unavailable at the timinterview since it has been left at home. As far as theinformant can recall, the vaccination were as follows:


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Vaccine 1stdose 2nddose 3rddose Booster Place

BCG + BGH

DPT + + + Private physicians cli

OPV + + + Private physicians cli

Hepatitis B + + +1stdose at BGH,

succeeding at Physicclinic

Measles + Private physicians cli

MMR + Health Center

HiB + + + Private physicians cli

Pneumococcal(conjugate)

Rotavirus + Health Center

Mother claimed that patients immunization was completed; Additional vaccine reRotavirus.


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PAST MEDICAL HISTORY

No history of previous hospitalization or surgicalintervention

No history of viral exanthematous disease

No known allergies to drugs and food


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FAMILY HISTORY

Both parents are presently well

(+) family history of HPN and bronchial asthmamaternal side

No family history of diabetes mellitus, arthritis, Cancer,CVD and CAD twinning, multi-fetal gestation, seizuredisorders, or congenital anomalies.


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SOCIAL AND ENVIRONMENTAL HISTOR

Mother, 28 year old, call center agent at Sitel, agraduate of BS HRM

Primary caregiver is the grandmother- has the sameillness as that of the patient : (+) cough and colds

Patient is an only child.


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Lives in a non-congested neighborhood, in a building tyhouse with 3 rooms and 6 occupants

Source of water for domestic purpose comes from Bagu

District

Drinking water is also from BAWADI: not properly boiled

They have 1 dog, which stays outside

Garbage is collected regularly every week

Toilet is indoor and flush-type

Hand washing is practiced especially before eating meawhen preparing the patients food

The mother claimed that the patients has the habit of picthings inside their house and put it in his mouth.


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REVIEW OF SYSTEMS General: (+) febrile episodes, (-) weight loss, (+) decreased oral

intake, (+) irritability

Integument: (-) rashes, (-) pallor, (-) jaundice, (-) dryness (-)diaphoresis

Special Sensory:

Head and Neck: (-) trauma, (-) nuchal rigidity, (-) cervicallymphadenopathy, (-) headache

Eyes: (-) discharges, (-) redness, (-) infection, (-) pain

Ears: (-) hearing loss, (-) discharges

Nose: (+) colds; (-) bleeding, (-) sneezing

Mouth and Throat: (-) dryness, (-) circumoral pallor, (-) ulcers, (-)bleeding, (-) tongue lesions

Respiratory: (+) productive cough, (-) wheezing, (-) tachypnea, (-)dyspnea


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Cardiovascular: (-) edema, (-) cyanosis, (-) known CHD

GIT: (-) abdominal distention, (-) abdominal pain (-) anor

vomiting, (+) diarrhea, (-) constipation, (-) change in bowhabits, (-) melena, (-) hematochizia

GUT: (-) dysuria, (-) hematuria, (-) frequency, (-) discharg

Musculoskeletal: (-) deformities, (-) swelling, (-) tenderne

Hematological: (-) easy bruisability, (-) bleeding

Endocrine: (-) excessive sweating, (-) chills, (-) weight chaNervous:(-) altered sensorium, (+) convulsions


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Chest and Lungs: symmetrical chest wall expansion; (+) subcostal retractions, (+) coarse crackles on mid and b

lung fields, (-) wheezes, (-) rhonchi Heart: adynamic precordium, PMI is at the 4thICS LMCL,

tachycardic with regular rhythm; no murmurs noted

Abdomen: slightlyglobular, non- distended, hyperactivesounds, tympanitic, soft, (-) direct tenderness (-) reboundtenderness, (-) organomegaly

Genitalia: grossly female

Extremities: (-) cyanosis, no lesions and no deformities, wsymmetrical peripheral pulses on both upper and lowerextremities, and with good capillary refill.


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Neurologic: Cerebral: awake, irritable

Cerebellar: (-) tremors

Cranial Nerves: CN I: can smell

CN II: can see

CN III, IV, VI: intact EOMs

CN V: can blink the eyes, (+) corneal reflex

CN VII: no facial asymmetry when smiling

CN VIII: can hear

CN IX, X: (+) gag reflex

CN XI: moves head side to side

CN XII: can protrude tongue


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Motor: good muscle tone, bulk and activity

Sensory : able to respond to touch and painstimuli

Reflexes: (+) Babinski, bilateral, (-) Ankle clonus

2++

Meningeal Signs: (-) nuchal rigidity, (-) Kernigssign, (-)Brudzinkissign


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PROBLEM-ORIENTED MEDICAL RECORD

PROBLEM #1: Cough and Colds, Fever, Poor Oral Intak


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SUBJECTIVE

S - 1 year, 3 months old female infant- (+) febrile episodes: Tmax of 38.5 C- (+) productive cough for a week; (+) whitish phlegm- (+) colds for a week : nasal secretions characterized as watery and clear- (+) history of post-tussive vomiting: 2x- (+) dyspnea: fast breathing, alar flaring- Primary caregiver is having the same illness/ condition- (+) family history of BA


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OBJECTIVE

General Survey: awake, febrile, and irritable, in moderate C

distress Vital signs: CR= 137 bpm, RR= 57 cpm, T= 38.9 C per

axilla SPO2 = 90%

HEENT: sunken eyeballs; (+) tears, (+) alar flaring, pinkish anmoist lips and buccal mucosa; (-)tonsillopharyngeal wallcongestion

Chest and Lungs: symmetrical chest wall expansion; (+)shallow subcostal retractions, (+) coarse crackles on mid anbibasal lung fields, (-) wheezes, (-) rhonchi

Extremities: (-) cyanosis, with symmetrical peripheral pulses both upper and lower extremities, and with good capillaryrefill.


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ASSESSMENT

PEDIATRIC COMMUNITY ACQUIRED PNEUMONIA

with Moderate signs of Dehydration

SYMPTOM MINIMAL OR NO MILD TO MODERATE SE


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DEHYDRATION DEHYDRATION DEHYD

Mental status Well, alert Normal, fatigues orrestless, irritable

Apatheticunco

Thirst Drinks normally,might refuse liquids

Thirsty, eager to drink Drinks poto

Heart rate Normal Normal to increased Tachycabradyca

sever

Quality of pulses Normal Normalto increased Weak, timpa

Breathing Normal Normal, fast D

Eyes Normal Slightly sunken Deepl

Mouth and tongue Moist Dry Par

Skinfold Instant recoil Recoil in


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PLAN

DIAGNOSTICS

CBCP

CXR - APL


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Complete Blood Count07/01/14 Patients Value Normal range

RBC Count 5.35 4.56.0 x 10 12/LHGB 138 120-170g/LHCT 0.382 0.40-0.54MCV 72 76-96 flMCH 26 27-32pgMCHC 362 320-360g/LWBC Count 22 5-10 x 109/LBands --- 0-7%Neutrophils 81.1 45-70%Lymphocytes 15.1 20-40%Eosinophils 0.2 0-8%Monocytes 3 0-12%Basophils 0.6 0-2%Platelet 295 150-400RBC morphology Normocytic, normochromic


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CXR- APL


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- Therapeutics: Medications:Ceftriaxone 200 mg IV q 12 hrs 50-75 mkd CD: 57.14 mkdParacetamol 100 mg IV 1q 4 hours RTC 10-20 mkd CD: 14.28 mkd

PLRS 1L x 58-59 ugtts/min (5% DT) O2 at 1-2 lpm/NC


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PROBLEM #2: LBM


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S: 1 year, 3 months old female infant (+) febrile episodes: Tmax of 38.5 C

4-5x diarrhea for 1 day, and stool was described to beyellowish in color and watery, non- bloody, and foul smellinamounting to approximately 30-40 cc per episode

Drinking water is from the BAWADI also; however, it is not

properly boiled The primary caregiver of the patient who is her grandmoth

the one who prepares her food.

Proper handwashing was said to be practiced at home


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O: General Survey: awake, febrile, and irritable

Vital signs: CR= 137 bpm, RR= 57 cpm, T= 38.9 C peraxilla SPO2 = 90%

HEENT: sunken eyeballs; (+) tears, , pinkish and moist lips anbuccal mucosa

Abdomen: slightlyglobular, non- distended, hyperactive

bowel sounds, tympanitic, soft, (-) direct tenderness (-)rebound tenderness, (-) organomegaly

Extremities: (-) cyanosis, with symmetrical peripheral pulses both upper and lower extremities, and with good capillary


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ASSESSMENT:

ACUTE GASTROENTERITIS WITH MODERATE SIGNS OFDEHYDRATION


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Diagnostics:

Stool Exam- Therapeutics:

PLRS 1L x 58-59 ugtts/min (5

DT)


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STOOL EXAMFECALYSISParasitology (5/9/2014)

COLOR Brown Consistency SoftMETHOD OVA OR PARASITE CYST OR TROPHOZOITEDirect Fecal Smear Negative Entamoeba histolytica/

entamoeba dispar cyst

Concentration

Method -

Occult blood Method: - Result: -Otherexaminations Pus cells:5-10/hpfRed Blood cells: 5-10

Yeast Cells: Negative


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AIA

With moderate signs of dehydration


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MEDICATION:

METRONIDAZOLE100G iv EVERY 8 HOURS

ED: 35-50 MKD

CD: 42.85 MKD


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PROBLEM #3: Convulsion, Fever


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S:

1 year, 3 months old female infant

(+) febrile episodes: Tmax of 38.5 C

Few hours PTA: One episode of seizure was noted whicwas characterized as upward rolling of the eyeballs astiffening and jerking of the legs, lasting about less tha

minutes. (-) family history of seizure disorder


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General Survey: awake, febrile, and irritable

Vital signs: CR= 137 bpm, RR= 57 cpm, T= 38.9 C peraxilla SPO2 = 90%

Neurologic: Cerebral: awake, irritable

Cerebellar: (-) tremors Cranial Nerves: CN I: can smell

CN II: can see

CN III, IV, VI: intact EOMs

CN V: can blink the eyes, (+) corneal reflex

CN VII: no facial asymmetry when smiling

CN VIII: can hear CN IX, X: (+) gag reflex

CN XI: moves head side to side

CN XII: can protrude tongue


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Motor: good muscle tone, bulk and activity

Sensory : able to respond to touch and painful stimuli Reflexes: (+) Babinski, bilateral, (-) Ankle clonus

++ ++

++ ++

Meningeal Signs: (-) nuchal rigidity, (-) Kernigssign, (-)

Brudzinkissign


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BENIGN FEBRILE CONVULSION, PROBABLY SEOCNDARYPCAP-C AND AGE WITH MODERATE SIGNS OFDEHYDRATION

Di i


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- Diagnostics: None at the moment

- Therapeutics: Medications:

Diazepam 2mg IV PRN for frank

seizure

ED: 0.2- 0.5 mkd CD: 0.285mkd

SEIZURE PRECAUTION!


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Acute intestinal amoebiasis

(DISCUSSION)


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Amoebiasis is a parasitic protozoan disease that affects thegut mucosa and liver, resulting in dysentery, colitis and liverabscess.

Entamoeba histolytica infects up to 10% of the world'spopulation; endemic foci are particularly common in thetropics, especially in areas with low socioeconomic andsanitary standards.

2 most common forms of disease

amebic colitis

amebic liver abscess


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Two morphologically identical but genetically distinct spe

Entamoeba: Entamoeba dispar

does not cause symptomatic disease

Entamoeba histolytica

pathogenic species, causes a spectrum of disease and can become in

Mode of transmission Feco-oral route Cyst passers are the main source of infection.

Cysts are resistant to harsh environment including concenof chlorine but can be killed by heating 55C.


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Amebiasis is the 3rdleading parasitic cause of deathworldwide

It is estimated that infection with E. histolytica leads tomillion cases of symptomatic disease and 40,000-110deaths annually


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AMEBIC COLITIS Parasitic invasion of the intestinal

mucosa Non-dysenteric colitis

Occur within 2 weeks of infection ordelayed for months

Gradual with colicky abdominal painand frequent bowel movement (6-8/day)

Diarrhea with tenesmus, blood stained,with fair amount of mucus with fewleukocytes

High incidence in 1-5 years of age

Dysentery Not very common (1% of total

prevalence of amebiasis in the wholeworld)

Very fatal

Rare

Fever, chills, severe diarrhea,dehydration and electrolytedisturbances

AMEBIC LIVER ABSCESS

Dissemination of theparasite to the liver

Rare in children

Diffuse liver enlargem


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Mouth - Cyst ingested

Invades gut mucosa cyst formation

Cyst

Passed in stool

Excyst to trophozoite

Trophozoite

Amoebic disease


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GAL-GAL/NACATTACHMENT

EPITHELIAL LAYERPENETRATION

FLASK- SHAPED ULCERINVASION


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A diagnosis of amebic colitis is made in the presence ofcompatible symptoms with detection of E. histolytica antigin stool.

E. histolytica II stool antigen detection test is able to distinguishhistolytica from E. dispar infection.

Microscopic examination of stool samples has a sensitivity o60%. Sensitivity can be increased to 85-95%by examining 3stools, since excretion of cysts can be intermittent Microscopy cannot differentiate between E. histolytica and E.

dispar unless phagocytosed erythrocytes (specific for E. histolyare seen


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Amoeboma.(localized granulomatous mass

misdiagnosed with carcinoma)

Hemorrhage.

Perforation of ulcer.(secondary peritonitis --- rare but fatal)

Stricture of colon.(secondary to fibrosis)

Appendicitis.


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Invasive amebiasis is treated with a nitroimidazole such asmetronidazole or tinidazole and then a luminal amebicide

Metronidazole: 35-50 mg/kg/day for 7-10 days

Tinidazole: 50 mg/kg/day for 3 days for colitis or 50 mg/kg/dfor 3-5 days for liver abscess

Followed by: Paromomycin (preferred): 25-35 mg/kg/day for 7 days

Diloxanide furoate: 20 mg/kg/day for 7 days or

Iodoquinol 30-40 mg/kg/day for 20 days


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Most infections evolve to either an asymptomatic carrstate or eradication. Extraintestinal infection carries aba 5% mortality rate.


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Exercising proper sanitation and avoiding fecal-oraltransmission

Regular examination of food handlers and thoroughinvestigation of diarrheal episodes may help identify thesource of infection

No prophylactic drug or vaccine is currently available foramebiasis

Immunization with a combination of GAL/Gal/Nac lectin aCpG oligodeoxynucleotides

Protective in amebic trophozoite challenge in animals


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PCAP- C

Acute intestinal Amoebiasis w/moderate signs of Dehydration

Benign Febrile Convulsion secondar


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Thank you for listenin

HAVE A NICE DAY!

- Roxiee

roxie amoeba

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