1. Chapter 5 Diarrhoea Case I

2. Case study: Sarah
Sarah, a 9 months old girl was brought to the hospital with diarrhoea for 5 days. She was restless and irritable.

3. What are the stages in the management of Sarah?

4. Stages in the management of a sick child (Ref. Chart 1, p. xxii)
Triage
Emergency treatment
History and examination
Laboratory investigations, if required
Main diagnosis and other diagnoses
Treatment
Supportive care
Monitoring
Discharge planning
Follow-up

5. At Triage – how to quickly assess for emergency signs
Take a brief history of the presenting problem
Take temperature and weigh the child
Listen for stridor or obstructed breathing
Look for cyanosis and for signs of respiratory distress (chest indrawing, tracheal tug), check SpO2
Feel the skin temperature of the hands and feet, feel the peripheral pulses for volume, check capillary refill time
Assess for lethargy and level of interaction.

6. Have you noticed any emergency or priority signs?
Temperature: 36.50C, weight 6.5kg, RR 40/min, pulse: 130/min, capillary refill time: 2 seconds, sunken eyes, normal skin turgor

7. Triage Emergency signs (Ref. p. 2, 6) Obstructed breathing
Severe respiratory distress
Central cyanosis
Signs of shock
Coma
Convulsions
Severe dehydration
Priority signs (Ref. p. 6)
Tiny baby
Temperature
Trauma
Pallor
Poisoning
Pain (severe)
Respiratory distress
Restless, irritable, lethargic
Referral
Malnutrition
Oedema of both feet
Burns

8. Triage Emergency signs (Ref. p. 2, 6) Obstructed breathing
Severe respiratory distress
Central cyanosis
Signs of shock
Coma
Convulsions
Severe dehydration
Priority signs (Ref. p. 6)
Tiny baby
Temperature
Trauma
Pallor
Poisoning
Pain (severe)
Respiratory distress
Restless, irritable, lethargic
Referral
Malnutrition
Oedema of both feet
Burns

9. History
Sarah was well until 5 days ago, then she started having loose watery stools 6-10 times per day.
Vomited the last 2 days, 2 times each day
There was no blood or pus in the stool.
Past medical history: previously well, no significant past history
Immunization: up to date according to vaccine schedule, measles vaccine due at 9 months
Social history: lives with her mother and sister, 4 years old
Medications: none

10. Examination
Sarah was crying continuously, she only stopped briefly when her mother put her to her breast. When she was offered ORS she drank eagerly.
Vital signs: temperature: 36.5 °C, RR: 40/min, pulse: 130/min
Weight: 6.5 kg
Eyes: sunken
Skin: normal skin turgor (skin pinch goes back immediately)
Chest: air entry was good bilaterally and there were no added sounds
Cardiovascular: both heart sounds were audible and there was no murmur
Abdomen: soft and doughy, bowel sounds active and there was no organomegaly
Neurology: restless and irritable; no neck stiffness

11. Differential diagnoses
List possible causes of the illness, in order they are likely, use clinical features to say which are most and least likely (Ref. p. 127)

12. Differential diagnoses
What clinical features make these diagnoses most or less likely?
Acute watery diarrhoea
Cholera
Dysentery
Persistent diarrhoea
Diarrhoea with severe malnutrition
Diarrhoea associated with recent antibiotic use
Intussusception

13. Classification of the severity of dehydration in children with diarrhoea
Signs or symptoms
Severe
dehydration
Two or more of the following signs:
lethargy/unconsciousness
sunken eyes
unable to drink or drinking poorly
skin pinch goes back very slowly (>2
seconds)
Some
restlessness, irritability
drinks eagerly, thirsty
skin pinch goes back slowly No
Not enough signs to classify as some or severe dehydration
(Ref. Table 12, p. 128)

14. Are any investigations needed to make a diagnosis ?

15. How would you treat Sarah?

16. Treatment Plan B (Ref. Chart 14, p. 135)
In the first 4 hours give 75 ml per kg of ORS as shown in table below
Show the mother how to give the child ORS solution, a teaspoonful every 1-2 minutes if the child is under 2 years; frequent sips from a cup for an older child

17. Supportive Care Check to see if there are problems (Ref. p. 132-136 )
Advise mother to continue to breastfeed whenever Sarah wants to feed
Infection control: hand washing

18. Monitoring and discharge planning
After 4 hours: reassess
Check the signs of dehydration
Check that the child has drank the ORS
Check that she has not vomited
Select the appropriate plan to continue
Show Sarah’s mother how to prepare ORS at home
Give her enough ORS packets to complete rehydration, and zinc for 7 days
Explain: how to give ORS safely at home, continue feeding, and when to return

19. Summary Sarah had acute watery diarrhoea and some dehydration
She was rehydrated with ORS and continued breast feeding
She was discharged on the same day after taking ORS for 4 hours (75ml/kg), without vomiting
At discharge she was alert, and able to drink and eat.
Her mother was given advice on how to give extra fluid, to continue feeding and to return to be checked the following day.