Question

Jenny, a twenty-two year old college graduate, has recently decided to spend two years as a missionary in a coastal African village. As part of her duties, she will work in the missionary clinic that has recently been established in the village. This clinic will provide routine medical care and a travelling physician and nurse will visit once each week. Jenny feels fortunate to have the opportunity to use the information that was presented to her in various classes she completed while in college. After completing a 4-month intensive training period (language classes, medical preparation for work in the clinic, and cultural enrichment), she departed for Africa. Upon her arrival, Jenny found that she would be spending most of her time in the clinic since the village had been without routine medical care for the past 2 years. The previous clinic was closed due to flooding and insufficient funds to rebuild. Initially, Jenny found that she was very dependent upon the physician’s weekly visits since her training was limited. Gradually, she found that she was beginning to call upon her training (both clinical and classroom) and she felt comfortable diagnosing and treating some of the more routine cases. One morning, a mother came in with her five-year-old child. The mother reported that the child had been unable to eat or drink anything for the past day because of vomiting. In addition, her child was experiencing severe diarrhea. Jenny asked the mother if any other family members were exhibiting similar symptoms, to which the mother replied that a few other members of the family had similar symptoms, however, not as severe. Jenny’s first thought was that the symptoms were very similar to those she had exhibited following a bout of food poisoning while in college. Since the villagers had no refrigeration and poor sanitation, Jenny gave the mother an electrolyte solution containing glucose similar to Gatorade® and told the mother to have the affected children consume this solution and nothing else for the next 24 hours. After that time, if the children were no longer vomiting, she could start feeding them tea and broth. Jenny also cautioned the mother that if the children did not seem to be getting better after 24 hours to bring the children back to the clinic. The next morning Jenny opened the clinic to find the mother, and not just the child she had seen the previous day, but three more of the woman’s children. All of the children were exhibiting similar symptoms that now included muscle cramping and excessive thirst in addition to diarrhea and vomiting. When checking the vital signs of the children, Jenny noticed increases in both the pulse and respiratory rates accompanied by decreased blood pressures. Uncertain as to the appropriate course of action, Jenny contacted the physician by radio. Upon conveying the histories and information to the physician, Jenny received instructions to keep the children at the clinic, start intravenous (IV) infusion with lactated Ringer’s solution, and allow the children to drink as much of the electrolyte solution with glucose as they would like. The physician also gave Jenny a list of laboratory tests to run on the blood, urine and stool samples that she should collect. Jenny started the IV infusions and gave each child some of the electrolyte solution. After this, she obtained stool, blood and urine samples from each child and asked the mother to leave the children with her for care and observation. The mother agreed and said she would return later that night to help with the children. The results of the tests run indicated severe metabolic acidosis, an increased hematocrit, hypokalemia, and the presence of Vibrio cholerae bacteria in the stool samples. Based on the results of these tests, the physician and Jenny diagnosed the children with cholera and obtained a more detailed history in an attempt to determine whether these individuals were the only ones exposed or whether these cases were the first of a possible epidemic. Jenny and the physician found that the family had recently visited relatives in a distant village where similar symptoms had been present in a number of families that had all celebrated a recent shellfish harvest. The physician prescribed continued IV infusions with lactated Ringer’s solution and electrolyte fluid replacement by mouth. The children were not allowed to consume other foods or drinks, especially coffee or any other beverages containing caffeine. The children were also told that once the vomiting stopped they could start consuming solid foods. The children were all treated with antibiotics and stool samples were taken from other family members to determine whether or not they were infected with Vibrio cholerae. Infected, asymptomatic individuals were treated with antibiotics. The physician later explained to Jenny that caffeine was prohibited because the toxin produced by the bacteria (termed choleragen) binds to the surface of the epithelial cells of the small intestine and activates adenylate cyclase. In addition, the toxin interferes with the active transport of sodium ions in the intestinal lumen. Using the medical terms you learned this week answer the following questions about this case

Why did Jenny initially suspect that the child and other family members were experiencing food poisoning? Upon further evaluation on the second day why would the child present an increased pulse and respiratory rate but decreased blood pressure?

Answer 1

1. Jenny 22 year old college graduate works in the clinic and depends on the physician. Physician visits clinic weekly. When Jenny was working in the clinic, a mother with five year child came to the clinic with vomiting and severe diarrhea. Even though some of her family members have been suffering from same symptoms but not severe as child. Jenny had experience same experience of similar symptoms while she was in college. Causes of symptoms include poor sanitation, improper food preparation, contamination of food, contaminated water. Symptoms of food poisoning are vomiting, diarrhea and affects in the family who have consumed same food. These symptoms are result of poor sanitation. Since the villager had poor sanitation and poor refrigeration that’s why she thought these symptoms are of food poisoning.

2. On second day, the mother with children visited the clinic, on evaluation, the children experiences increased pulse rate and respiratory rate and decreased blood pressure along with muscle cramps and excessive thirst. Severe diarrhea and vomiting causes the electrolyte imbalances such as hypokalemia, hyponatremia as a result of the bacteria which enter and colonize the small intestine. This bacteria produces enterotoxin and this toxin binds to the intestinal walls and activates chloride channels and thereby releases large quantities of water, electrolyte and bicarbonate. There by fluid is secreted and severe diarrhea occurs

    Muscle cramping is due to hypokalemia as a result of diarrhea and vomiting. Because loss of potassium from the diarrhea and this turns release of potassium from the cells

  Thirst is due to dehydration and hyper secretion of water from the body

Metabolic acidosis occurs due to loss of sodium and HCO3 from the body. This metabolic acidosis causes increase and rapid breath. This increased respiratory rate is compensatory mechanism

Increased heamtocrit is due to reduction of fluid in the vascular compartment as a result of diarrhea, vomiting

Hypotension or decreased blood pressure caused by the loss of blood or fluid volume in the body. The fluid loss can be felt by the plasma and interstitial fluid is shifted to plasma to compensate. After the reduction interstitial fluid loss and plasma loss, then blood pressure begin to fall and cause hypotension.

Tachycardia is due to compensatory mechanism in the case of diarrhea. That is heart is trying to pump out fluid by increasing the heart rate to compensate fluid loss in the body as a result of vomiting and diarrhea

Tachycardia and hyperpnoea and hypotension are results of severe diarrhea and vomiting which was casued by the contaminated food.any beverage could aggraevate diarrheal symptoms. food increases diarrheal symptoms.