A detailed physical evaluation should be done for a child presenting with acute diarrhea.
Goes back quickly
Goes back slowly
Goes back very slowly
Faster than normal
Very fast, weak or absent pulse
Use PLAN A
Weigh the child.
Weigh the child.
PLAN B PLAN C
Fluid deficit < 5% body wt 5-10% body wt >10% body wt
However if the child is severely dehydrated, treatment should be started without delay after which a detailed assessment should be done
Aims of clinical assessment are
(a) To assess severity of dehydration
(b) To diagnose dysentery
(c) To evaluate nutritional status and feeding practices of the child
(d) To detect any concurrent infection
(e) To determine the child's immunization history
Table-2 details the physical findings associated with dehydration of different degrees of severity. These findings occur irrespective of the etiology of diarrhea.
Clinical signs are used to classify the child as having either no dehydration, some dehydration or severe dehydration. It is important to weigh the child. If the child's pre-illness status is known, the change from this value provides an accurate assessment of the magnitude of fluid losses.
Most infants and children appear sick when dehydrated. When fluid deficits reach 50 ml/kg, tachycardia develops. Rate of breathing is increased in children with severe dehydration due to acidosis. Signs of circulatory failure appear with increasing degrees of dehydration. Skin over the arms and legs become moist and cool and nail may be cyanosed with severe dehydration. Shock manifested by tachycardia, a thin, thready pulse, cyanosis and low blood pressure may supervene with severe dehydration. The assessment of hydration status may be difficult in a child with malnutrition.Capillary refill time (CFT) is useful to quantitate the fluid losses. It is done by blanching the ball of the patient's thumb or great toe with pressure and estimating the number of seconds it takes for blood to reappear in the tissue.
CFT < 2 sec signifies fluid loss < 50 ml/kg,
CFT 2-3 seconds signifies fluid loss of 50 to 90 ml/kg and
CFT > 3 seconds signifies fluid loss > 100 ml/kg. It is important to assess child's vital signs and carefully review recent oral fluid intake.
In addition the child may have signs of electrolyte imbalance such as hypokalemia (weakness, ileus with abdominal distension) or hypernatremia (warm "doughy" skin, hypertonia, hypereflexia or irritability).
Physical examination may detect other infections like pneumonia or otitis media.
Indications of admission of a child with diarrhea: