Pharmacotherapy Case Study: Pediatric Gastroenteritis By: Dr. Nehad Ahmed

 

Pharmacotherapy Case Study: Pediatric Gastroenteritis By: Dr. Nehad Ahmed

 

Chief Complaint:

A 4-year-old male presents with a 2-day history of vomiting, diarrhea, and fever after playing with other children at a local park. The symptoms started suddenly and have progressively worsened.

Subjective Data:

History of Present Illness (HPI):

·        The patient’s parents report that he began having vomiting and diarrhea approximately 2 days ago, after spending several hours at a local park, playing with other children.

·        The vomiting is described as frequent, occurring 3-4 times per day, particularly after meals. The vomit is non-bilious, without blood or mucus.

·        The diarrhea started on the same day and has been watery, occurring 4-5 times per day. There is no blood or mucus in the stool, and the stool is described as pale in color.

·        The child has also been running a low-grade fever, peaking at 101°F (38.3°C) in the evenings.

·        The parents report that the child has been lethargic and has decreased his usual activity level, though he has been drinking small amounts of fluids, such as water and oral rehydration solutions (ORS).

·        The parents have tried offering the child small amounts of food, but he refuses to eat most of the time, except for some crackers and a little soup.

·        There has been no recent history of travel or contact with anyone else who is sick, but the child’s older sibling recently had a similar illness.

·        The parents are concerned about dehydration due to the child’s decreased intake of fluids and frequent vomiting and diarrhea.

Past Medical History (PMH):

·        No significant past medical history.

·        No history of chronic gastrointestinal disorders (e.g., Crohn’s disease, celiac disease).

·        Up-to-date on vaccinations.

Medications:

·        No regular medications.

·        No known drug allergies (NKDA).

Family History:

·        Mother with a history of allergic rhinitis.

·        Father with a history of mild asthma.

·        No family history of gastrointestinal conditions (e.g., inflammatory bowel disease).

Social History:

·        The patient lives with both parents and an older sibling in a home with no smoking or pets.

·        The family has not traveled recently.

·        The child attends daycare, where he interacts with other children, and the parents have reported a few children in the daycare having gastrointestinal symptoms similar to his.

·        The child is generally healthy, has no history of developmental delays, and is up to date on vaccinations.

Review of Systems (ROS):

·        Gastrointestinal: Vomiting, watery diarrhea, decreased appetite. No blood in the stool or vomit. No abdominal pain or cramping.

·        Cardiovascular: No chest pain or palpitations.

·        Respiratory: No cough or shortness of breath.

·        Neurological: No headaches, dizziness, or seizures.

·        Genitourinary: No dysuria or changes in urine output.

 

Objective Data:

Vital Signs:

·        Blood Pressure: 95/60 mmHg

·        Heart Rate: 120 bpm

·        Respiratory Rate: 22 breaths/min

·        Temperature: 101°F (38.3°C) (low-grade fever)

·        Weight: 34 lbs (15.4 kg)

·        Height: 3'4" (101 cm)

Physical Exam:

·        General: Alert but appears lethargic, mildly irritable. Looks mildly dehydrated with dry mucous membranes.

·        HEENT: No signs of jaundice. Dry mouth and lips.

·        Abdomen: Soft, non-distended. Mild tenderness to palpation in the lower abdomen but no rebound tenderness or guarding. Normal bowel sounds.

·        Cardiovascular: Tachycardic with a regular rhythm, no murmurs or gallops.

·        Respiratory: Clear to auscultation, no wheezing or crackles.

·        Skin: Skin turgor slightly decreased, no rashes or jaundice.

·        Neurological: Normal tone, alert and responsive to verbal stimuli, no focal deficits.

Labs and Imaging:

·        Complete Blood Count (CBC):

o   Hemoglobin: 11.9 g/dL (normal)

o   Hematocrit: 35% (normal)

o   White Blood Cell Count: 10,200/mm³ (mildly elevated, likely due to infection)

o   Platelets: 320,000/mm³ (normal)

·        Basic Metabolic Panel (BMP):

o   Sodium: 136 mEq/L (normal)

o   Potassium: 4.0 mEq/L (normal)

o   Chloride: 102 mEq/L (normal)

o   Bicarbonate: 20 mEq/L (slightly low, could indicate mild acidosis due to diarrhea)

o   Blood Urea Nitrogen (BUN): 12 mg/dL (normal)

o   Creatinine: 0.3 mg/dL (normal)

o   Glucose: 95 mg/dL (normal)

·        Stool Culture: Negative for pathogenic bacteria (e.g., Salmonella, E. coli, Shigella, Campylobacter).

·        Rotavirus/Enteric Pathogen Panel: Positive for norovirus (common viral cause of pediatric gastroenteritis).

·        Urinalysis: Normal, with no signs of dehydration or urinary tract infection.

Assessment:

The patient presents with typical signs and symptoms of acute viral gastroenteritis, likely caused by norovirus, which is the most common viral pathogen in pediatric gastroenteritis. The patient's symptoms (vomiting, diarrhea, fever, mild dehydration) are consistent with a self-limited viral infection. The positive rotavirus/enteric pathogen panel supports this diagnosis.

The primary concern is mild dehydration, as evidenced by the child’s dry mouth and slightly decreased skin turgor. However, there is no evidence of severe dehydration (e.g., sunken eyes, lethargy, or decreased urine output).

Given the nature of viral gastroenteritis, the illness is expected to resolve on its own within a few days, although supportive care is necessary to manage symptoms and prevent dehydration.

Plan:

Pharmacologic Treatment:

1.     Anti-emetics:

o   Ondansetron (Zofran) 2 mg orally every 8 hours as needed for nausea and vomiting. The patient’s age is appropriate for this medication, and it can help reduce vomiting, which may aid in fluid retention and decrease discomfort.

2.     Oral Rehydration:

o   Recommend oral rehydration solutions (ORS) (e.g., Pedialyte) in small, frequent sips to prevent dehydration and replace lost electrolytes. Encourage the parents to give 5-10 mL every 5 minutes, increasing the volume as tolerated.

o   Encourage the patient to drink fluids at least every 30 minutes, with increased fluid intake if vomiting is controlled.

3.     Antipyretics:

o   Acetaminophen (Tylenol) 160 mg orally every 4-6 hours for fever and discomfort (as needed), ensuring that the maximum daily dose is not exceeded.

Non-Pharmacologic Treatment:

1.     Dietary Modifications:

o   Encourage small, bland meals (e.g., crackers, rice, applesauce, toast) when the patient is able to eat.

o   Avoid greasy, fatty, or spicy foods until the patient fully recovers.

o   If the patient refuses solid foods, continue to encourage fluid intake with ORS or clear fluids until appetite returns.

2.     Dehydration Prevention:

o   Continue oral rehydration with ORS for the next 24-48 hours or until the child is able to tolerate a regular diet.

o   Monitor for signs of dehydration, such as reduced urine output or irritability, and seek further medical help if these signs appear.

Monitoring and Follow-Up:

·        Follow-up in 48 hours or sooner if symptoms worsen, especially if the child’s hydration status declines.

·        If the child continues to have persistent vomiting or diarrhea, or develops severe dehydration (sunken eyes, dry mouth, no urine output), consider hospitalization for IV fluids.

 

 

Patient Education:

·        Educate the parents on the importance of oral rehydration to avoid dehydration. Emphasize that small, frequent sips are key, especially if the child is vomiting.

·        Inform the parents that viral gastroenteritis typically resolves on its own within 2-3 days and that the child should avoid dairy products until the diarrhea resolves, as lactose intolerance may temporarily occur.

·        Discuss the importance of hand hygiene to prevent the spread of the virus, as norovirus is highly contagious.

·        Provide guidance on signs of dehydration and when to seek further medical attention.

Referral:

·        No referral is needed at this time unless symptoms significantly worsen or if dehydration becomes more severe.

Long-Term Management:

·        Reinforce the importance of proper handwashing and food hygiene practices, especially in communal settings like daycare, to help prevent future episodes of gastroenteritis.