5.2 Initial clinical assessment

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    For assessment in pregnant women, see Section 5.7 and in severely malnourished children, see Section 5.8. For children with severe anaemia, see also Section 5.9.

    5.2.1 Definition of a clinical case

    In an epidemic context, a patient with acute watery diarrhoea (3 or more liquid stools per day) with or without vomiting, with or without dehydration, is a clinical case of cholera.

    5.2.2 Clinical examination

    1) Recognize danger signs

    The first step is to determine whether there are signs of hypovolaemic shock.

     

    • Loss of consciousness (coma) or decreased level of consciousness (lethargy)
    • Absent pulse or weak pulse difficult to palpate
    • Very rapid breathing or gasping or cyanosis

     

    Notes:

    – Lethargy: a lethargic patient is a somnolent patient who cannot be fully awakened, even with stimulation.
    – Pulse: routinely counting the pulse rate is unnecessary. Verify if the pulse is palpable or not and if the pulsations are strong (readily palpable) or weak (difficult to palpate).

     

    In the presence of a single danger sign, it is urgent to establish intravenous access and begin the protocol for severe dehydration. The remainder of the clinical examination can be competed once rehydration has commenced.

     

    In children under 5 years, additional danger signs should be specifically assessed, when a trained examiner is available. The presence of one of these danger signs also justifies treatment for severe dehydration:
    – Temperature gradient between the body and the extremities (cold hands and feet) AND a capillary refill time > 3 seconds.
    – Heart rate (HR) outside the normal range for age, in the absence of another pathology explaining the anomaly.
    – Respiratory rate (RR) outside the normal range for age, in the absence of another pathology explaining the anomaly.

     

    Table 5.1 – Abnormal heart and respiratory rates in children 0-5 years

     

    Parameters

    0 to
    < 2 months

    2 to
    < 12 months

    1 to

    < 3 years

    3 to 5 years
    HR

    > 180
    < 100

    > 180
    < 90

    > 150
    < 90

    > 140
    < 80

    RR > 60 > 50 > 40 > 40


    2) Complete the evaluation of dehydration

    In the absence of danger signs (or after having urgently started IV infusion in patients with danger signs), continue the evaluation using the table below:

     

    Table 5.2 – Evaluation of dehydration (adapted from the WHO)

     

    Mental status Normal, awake Agitated, irritable

    Lethargic or
    unconscious

    Radial pulse Easily palpable

    Palpable
    (possibly rapid)

    Difficult to palpate
    (weak)
    or absent

    Eyes Normal Sunken Sunken
    Skin pinch Disappears rapidly

    Disappears slowly
    (< 2 seconds)

    Disappears very slowly
    (> 2 seconds)

    Thirst Drinks normally

    Thirsty,
    drinks avidly

    Incapable
    or drinks very little

    DIAGNOSIS

    NO DEHYDRATION

    SOME DEHYDRATION

    SEVERE DEHYDRATION

     

    Notes:
    – Sunken eyes are a sign of dehydration (loss of soft tissue volume causing eyes to sink into their orbits) but may be a normal feature in some children. Ask the mother if the child’s eyes are the same as usual or are more sunken than usual.

     

    – Skin pinch: this test evaluates the loss of skin elasticity due to a decrease in water content. The slower the skin pinch disappears, the greater the degree of dehydration. Skin pinch is assessed by pinching the skin of the abdomen between the thumb and forefinger, without twisting.
    In the elderly, this sign is not as reliable, as normal aging diminishes skin elasticity. In these patients, checking skin pinch can be done on the chest below the clavicle.

     

    – Thirst is not always a good indicator of dehydration. Severely dehydrated patients and the elderly may not feel thirsty, even in the presence of clear signs of dehydration. The objective is to determine if the patient is able to drink, rather than the level of thirst. If the patient drinks normally or avidly, then oral rehydration is indicated and is likely to succeed. Those who have difficulty drinking will require close surveillance as they risk failing oral therapy, necessitating a change in protocol (e.g. switching to IV rehydration).

     

    3) Decide which treatment to give

     

    Table 5.3 – Therapeutic decision

     

    Signs/symptoms Diagnosis Decision

    • One or more danger signs
    OR
    • At least 2 of the following signs a Citation a. The diagnosis is based on the association of at least two signs due to the lack of specificity of each sign taken individually.   :
    – very sunken eyes
    – skin pinch very slow to disappear (> 2 sec.)
    – the patient drinks very little

    Severe
    dehydration

    Treatment plan C

    • No danger signs
    AND
    • At least 2 of the following signs a Citation a. The diagnosis is based on the association of at least two signs due to the lack of specificity of each sign taken individually.   :
    – eyes lightly sunken
    – skin pinch disappears slowly (< 2 sec.)
    – the patient is very thirsty and drinks avidly

    Some
    dehydration

    Treatment plan B

    No signs of some or severe dehydration

    No
    dehydration

    Treatment plan A

     

    4) Weigh the patient

    Weigh the patient if possible (at least children under 5 years) to decide the quantity of fluid to be administered or use an age-based weight estimate.

     

    5) Look for concomitant illnesses

    In the event of fever in a patient who meets the definition of a cholera case, look for co-infection (malaria, respiratory infection, etc.) and treat accordingly. See Clinical guidelines, MSF. Relevant tests should not delay rehydration therapy.
    The rehydration protocols may be modified and closer monitoring required in the event of a concomitant pathology in patients at particular risk (Section 5.9).

     

    Footnotes
    • (a) The diagnosis is based on the association of at least two signs due to the lack of specificity of each sign taken individually.