Case Presentation in Bedside Teaching (BST)

7:14:00 PM

OMGGGGG, we did it! Well, we are the only girls that never present in front of Prof. Safwat. I'm so thankful to my patient and his mother for giving so much consideration and cooperation with me through out the clerking and physical examination. My patient look a bit small for a 2 years old boy. So I was wondering whether to plot the growth chart or not. Phewww, I just too lazy (Please don't be like me!) to plot his growth chart because mother didn't remember his boy's weight accordingly, never mind then!

So my patient was a 2 years 5 months old boy living in Rantau Panjang. He came due to fever and rapid breathing. I know you will be like - Ohhh, its a pneumonia case ! Not so fast gaisss!

Patient has history of on and off, non-productive cough for a week. Mother said it was a mild cough so she didn/t seek for any medication for that. - I forgot to ask mother when the cough got worsen, was it by day or by night..

7 days later he develop diarrhoea and according to mother it was more than 8 times/day. Mother described the diarrhoea was yellowish, watery and there was faulty smelly. Diarrhoea was not associated with abdominal pain, but there was vomiting up to 5 times/day. Vomiting was aggravated by meal and the contain of vomitus was food particles. There was poor food intake, but patient can tolerate liquid intake. Patient seems lethargic. - It was diarrhoea started first then only the vomiting. Diarrhoea was described as watery and yellowish - more to viral GE but there was faulty smelly which brought the case more to bacterial GE. Confusing huh? Hahaha.

Around 2 am on next day, patient develop high fever (according to mother). It was warm to touch but there was no documented temperature. Fever was associated with chills and rigor ,but there was no fitting. Mother gave syrup PCM, but only temporarily resolve about 8 hours. - Fever was high and associated with chills and rigor should be suggesting a bacterial GE right?

In the evening, mother noticed there was rapid breathing during patient was sleeping. So she brought him to ED. - Cough, fever and rapid breathing ? This is the Pneumonia Triad !

Otherwise, there were no rashes, no sick contact, not from dengue prone area, no recent water activity, no history of outside food intake and mother not sure about rodent in the house but she said she never see rodents before in her house. Patient is the only one having these symptoms in family.

This is his 5th hospitalization. 3 of it was due to bronchopneumonia and treated with nebulizer. His 4th hospitalization was due to leptospirosis in 2015.

There were no malignancy or chronic illness in in the family. His father is a smoker and mostly he smoke outside the house. Patient was delivered full term by normal vaginal delivery with 2.6 kg.

Other history were uneventful. Upon admission, his temperature was 39 degree Celsius. His respiratory rate was 36. On auscultation on lungs, there is bilateral crepitation. No rhonci.

Lab Investigations

TWC is normal.
Lymphocyte was 57.3% and Neutrophil was 29.7%.
Platelet was 255.
Liver function test; A/G ratio elevated and Alkaline phospatase was 266.79 U/L.
Stool for rotavirus is positive.
Stool culture and sensitivity: Negative
Lepto rapid test was inconclusive.

Hmm, so what is your differential diagnosis gaisss?

Differential diagnosis:

Parenteral gastroenteritis due to viral infection
Viral Gastroenteritis
Bacterial Gastroenteritis
Pneumonia
Leptospirosis

Finally can rest now after presenting case to Prof. I got 8.5/10 from him. He said it was the best he can give me. He said 9 is too exaggerating hahaha. I don't mind tho. At least he said he felt good and ease that we did well in BST. Exam in 6 days now. May Allah ease !