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Example of Case Study

Much Ado About Stools
Giardiasis Strikes Middle America

Clinical Case Study #1

Brandon Russell, MICT-S
Cowley County Community College
Slade Griffiths, Instructor

Introduction
Patient XX, a 2 year-old XX male, presented to the XX with complaints of diarrhea, anorexia, polydipsia, and lethargy. XX's mother, a XX-year-old XX female, noted the presenting signs and symptoms and brought XX to the XX for evaluation.

Subjective
Identifying Data: XX is a 2 year 4 month old XX male, forth child and second son of XX and XX of XX. XXR. is employed as a XX and XX is a stay-at-home mother of five children. XX is a regular patient of this clinic, and PMH and previous exams are all on record at this facility.
Chief Complaints: XX neither indicates nor verbalizes any chief complaints; all were noted and brought forward by the mother, XX XX states that XX began having a flattened affect and anorexia approximately three days prior. Yesterday morning XX began exhibiting polydipsia and diarrhea.
Present Illness: XX denies that any other member of the family currently displays the S/S exhibited by XX, & states she believes he has a "stomach bug". It appears that no other pathology presents in XX that would make the current S/S of any secondary gain.
Birth History: XX was the XX of XX children to XX. XX had no complications during birth, and records indicate no pre-natal, natal, or neonatal complications or distress.
General Growth: XX is median on the appropriate scale for height/weight development, has no congenital defects, has shown normal physical growth after the first 12 months, successfully met all developmental milestones within acceptable limits, and records indicate no problems in diet, sleep, toileting, speech, or habits.
Childhood Illnesses: XX, despite apparent normal growth and development has significant PMH for a child of two years. XX is current on all vaccinations and has been treated in the past for conjunctivitis, bronchitis, gastroenteritis, otitis media & externae, pharyngitis, cystitis, and Rickets. It was discovered that XX developed the Rickets due to his mother's social customs and XX seems to suffer no lasting effects from the Rickets. XX has never suffered accident or trauma, has had no surgery, and was only hospitalized for 2 days as part of the treatment for Rickets.
Allergies: PCN
Immunizations: current & correct
Meds: none
Screenings: none
Family History: XX's immediate family has no history of illness that would likely affect XX at his current age and stage of development.

Objective
On exam vital signs were P: 110, R: 30, B/P: not taken, Temp: 100.1. Pt. is alert and oriented to place, person and name, but presents with no response to being taken from his mother or being subjected to an exam, and therefore must have a flattened affect. Skin is warm to hot, dry, and consistent in color with minor tenting noted on the forearms. HEENT is negative with eyes PERL, strong red reflex, nose clear to discharge, growths or blockage, ears with sharp reflective TM's, no discharge or pain, and throat shows no wounds, tonsils are normal in size, appearance, & color, with midline uvula and no oral swelling; incisors, k9's, and first molar pairs all present and normal. Chest normal in appearance with no dyspnea noted. On auscultation lungs had CBBS, and equal chest rise with no retractions or accessory muscle usage noted. Heart tones were unremarkable. Abdomen has hyperactive bowel sounds in the lower quadrants, and upon palpation is soft, but patient seems to indicate tenderness in all quadrants through withdraw. No deformities, masses, swelling, or pulsating noted on palpation. Anus and surrounding tissues appear aggravated from recent and frequent cleaning following diarrhea, and some runny, brown stool was noted in the patient's training pants. Extremities and posterior thorax are normal and patient can ambulate without assistance.
Samples for both UA and stool cultures were obtained and sent to the lab. All UA findings were within normal limits, but stool culture showed Giardia lamblia trophozoites present in sufficient numbers to warrant a diagnosis of Giardiasis (Giardia). This is a diagnosis that could produce all other S/S of the chief complaint that were noted.

Pathophysiology of Diagnosis
Giardia lamblia is a species of the genus protozoa. This protozoan is bi-nucleated and possesses four sets of flagella. It most commonly gains entrance to the human body through the fecal/oral route and infests the intestinal mucosa where it can obtain nutrients. Protozoan form G. lamblia are destroyed by the concentration of chlorine in most domestic water supplies, however, Giardia cysts can easily withstand these same chlorine concentrations. Therefore, the most common route of infection is through ingestion of food or water contaminated with fecal matter particles containing the Giardia cysts.
Once infested in the intestine, studies have shown that G. lamblia interferes with the absorption of fats, but few other nutrients. Infestation can present with signs and symptoms of diarrhea, fever, cramps, anorexia, nausea, weakness, weight loss, abdominal distention, flatulence, greasy stools, belching and vomiting. Symptom onset is usually around two weeks after exposure, and if untreated can last indefinitely, but usually only two to three months. The perpetuation and epidemiology of G. lamblia follows the standard three-phase parasitic form (ingestion, infestation, excretion-infection) through fecal exposure routes.
Except for ensuring clean water quality, there is no known chemoprophylaxis for Giardiasis. Treatment, though, is usually uncomplicated and involves a standard course of metronidazole, furazolidone, or quinacrine.

Treatment Performed
XX was given a prescription for metronidazole (Flagyl). Standard dosage for the treatment of Giardiasis in children is 5mg/kg P.O. t.i.d. x 5 days. XX's current weight was 28 lbs (~ 13 kg), making XX's needed dose 65mg P.O. t.i.d. x 5 days. The lowest dosage of metronidazole tablets available is 250mg/tablet, which created somewhat of a problem in treating XX However, the local pharmacist was contacted and he was able to divide the 250mg tablets into quarters, making each tablet section dosage around 62.5mg. So, XX was given a prescription for 5 tablets divided into quarters (20 62.5mg doses) and XX's mother was instructed to grind up the quarter tablet portions and place a quarter ground tablet into one small serving of pudding and feed it to XX three times daily until out of the prescription. The treatment course then lasted almost one full week, and although it was a longer course with a greater total dose than recommended, it was felt this would be more effective given the questionable method of administration, which by its very nature, left ample room for error. XX's mother was also given instructions to return to XX in one week, following the full course of chemotherapy, for a follow-up exam, and if S/S worsened in any way to return immediately. XX's mother was also given instructions as to the infectious state of XX's stool and was told to ensure it was not allowed to contaminate any surfaces and that no other children in the family were to come into contact with XX's stool.
Following the one-week of treatment with metronidazole all of XX's S/S were absent, and XX had returned to normal activity & diet. XX's mother reported that XX began showing solid stools and relief of the S/S about four days following the start of therapy. A repeat lab analysis of XX's stool sample was negative for any G. lamblia infestation.

Discussion
XX's case was interesting since Giardiasis not a common infection in developed areas of industrialized countries. To date it is still unknown how XX contracted Giardiasis, and although several educated guesses were made, they were, indeed, guesses. No other members of the community or of XX's family have, to date, shown any S/S of Giardiasis. Had anyone in the community or in XX's family also contracted Giardiasis it would have created an interesting minor epidemic, however XX was simply an isolated case of unknown etiology.
The other interesting aspect of XX's case was the difficulty presented in providing chemotherapy. Although the standard course of treatment for Giardiasis is quite simple, XX's age, weight and the availability of medication only in certain dosages made treatment a challenge. I was very impressed with the adaptability and creativeness demonstrated by the healthcare providers in XX in overcoming these difficulties.
One last consideration would be the nature of the parasitic spread of this disease as it relates to EMS. Although universal precautions are always at the forefront of EMS care, this case demonstrates how a case that presents as a minor illness (a child with diarrhea) could have created a serious infectious risk to any healthcare providers, equipment, or facilities which came in contact with particles of XX's fecal matter. This case only emphasizes the fact that every kind of pathology carries a danger of infection.

References Clayton, T.L., MD, MPH. Editor. (1989). Taber's Cyclopedic Medical Dictonary, 16th Ed. [textbook]. F.A. Davis Company: Philadelphia.

A special thanks to Brandon for allowing this to be used for an example for future MICT students.

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