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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