Case presentation
Paediatrics
Presented by
Anand Hegde
Core member of whitearmy
Demographic information
• Name-Mr ABC
• Age-10months
• Sex –male
• Adress-malalli,kundgol taluk
• Religion- hindu
• Informant – Ms xyz( mother )
• Age-24yrs
• Education-3rd standard
• Date of admission-23/02/2020
• Date of examination-27/02/2020
Chief complaints
• Fever for 5days
• Loose stools for 4days
History of present illness
• Child was apparently alright 5 days back the the child developed
fever, continuous type, Moderate degree, not associated with rigors
or any rashes, No diurnal variation and relived on medication
• Mother also complains of passage of loose stools by The baby since 4
days which was sudden In onset, watery in consistency, Non foul
smelling, initially 5-7 episode per day later increased to 8-10 episode
per day , yellowish in colour, non blood tinged,scanty in amount no
passage of worms in stool
• Mother gives history excessive thirst in baby and sunken eyeball
which relieved after coming to hospital
• No history of vomiting
• No history of any precipitating food intake
• No history of distention of abdomen
• No history of crying during micturition
• No history of edema ,baggy skin, Decreased activity
• No history of any drug intake
• No history of decreased urine output
• No history of weakness, convulsions
Past history
• No similar complaints in the past
• No history of previous surgery
Birth history
Antenatal history
• Booked case uneventful
• Anomaly scan was done
• Iron folic acid tablet taken
• No history of fever with rashes
• No history of antepartum haemorrhage
• No exposure to radiation
Natal history
• Full term vaginal delivery At 9 months 16 days
• Birth weight-2.4kg Cried immediately after birth
• Urine and meconium passed after 2 hours of birth
• No history of admission to NICU
• Breast feeding started within an hour after birth
Postnatal history
• No history of neonatal Jaundice
• Exclusivelyly breastfed for 6months and continued for 1year
• Supplementary food was given after 6 months
• No history of any infection
Developmental history
Gross
• Neck control at -3 month
• Roll over- 6month
• Sitting with support-7 month
• Standing with support -9 month
Fine motor
• Bidextrous grasp -4 month
• Unidextrose grasp -6month
• Mature pincer grasp-9 month
Social
• Recognised mother-3 month
• Waves bye bye -9month
Language
• Speak monosylabals-6 month
Developmental milestones achieved regularly
Immunization history
• Immunized till date
• Last vaccine -MR,JE, Vitamin A at 9month
• Rota virus vaccine not taken
Nutritional history
• Morning- 1 banana -110k cal- 1.g Protein
• 4 Biscuits - 80 kcal – 1g protein
• Afternoon – 1 glass Milk-160 k cal -8 g
. Ragi malt. -110k cal -2g
• Evening -4 biscuits-80 k cal 1g protien
• Night – Smashed rice and vegetables-110k cal -2g protein
Total- 650k cal ,15g protein
Required – 800 cal ,16g
Deficient- 250 k cal ,1g
Percentage – 30%in calories，6.25% in protien
Family history
• Non consanguineous marriage
• Married life -2 years
• No similar Complaints in other family members
Socioeconomic status
• Father is a farmer And studied till SSLC
• Belongs to class 4 socioeconomic status according to kuppuswamy
classification
• Lives in a Kucha house with overcrowding and with good ventilation
• No open defication , drink filtered water water supplies from
municipal corporation they store in vessel use dipping type
• Summary
Here is a 10 month old male child who is born to a non
consanguineous married couple belonging to class 4 socioeconomic
status ,who consumes a diet Which is 30% deficient in calories and
6.25% deficient in protien ,who is immunized upto date with normal
developmenal milestones and with no similar complaints in past. Now
comes with chief complaint of , fever since 5 days ,loose stools since 4
days
EXAMINATION
General survey
Here is a 10month old male child which is alert,active and playful
Vital signs
Temperature- 98.5° farenhiet measured in axilla
Pulse -114 beats per minute good volume, no radio radial or radio femoral
delay – normal
Respiratory rate-38cycles per minute- normal
Blood pressure-70/50mm Hg
Head to toe examination
Sign of dehydration
Tears present
Tongue moist
Not thirsty
Skin pinch –retracts immediately
• Hair –normal
• Anterior fontanel- appear to be sunken
• Posterior fontanel – closed
• Eye- pallor is present
. Icterus is not present
. No features of vitamin A deficiency
• Nose- normal
• Teeth –normal
• Oral cavity- Good Hygiene no features of anaemia
• Nails – normal
• Skin – On pinching the skin, it goes back immediately
• - Mangolian spots present on back
• Chest ,Spine and back normal
• Pelvis- There is loss of pad of fat in groin
• No cyanosis, clubbing, lymphadenopathy,edema
Anthropometry
Observed Expected Inference
Weight 6.7 kg 10 .7kg <-3 SD
Length 71 cm 76cm <-1 SD
Head 44 cm 45cm Normal
circumference
Mid arm 12cm >13.5cm <-2 SD
circumference
• Systemic examination
Per abdomen examination
INSPECTION
• Abdomen is distended Uniformly
• Umballicus central and everted
• Corresponding quadrants move equally with respiration
• No dialated veins Present ,no scars, no pulsation
• Hernial orifices normal
• External genitalia normal
PALPATION
• No local rise of temperate,no tenderness
• On Deep palpation
• Abdomen is soft ,no organomegaly appreciated
PERCUSSION
• Tympanic note heard
AUSCULTATION
• Normal bowel sounds heard
• Other systems
• CVS-
-No raised JVP, S1 S2 heard no murmur
• RS –
. Normal vesicular breath sounds heard Bilateral equal air entry no
added sounds
• CNS- No altered sensorium , sensory and motor system examination
is normal
• DIAGNOSIS
Case of Acute diarrhoeal disease of infective pathology With No
dehydration and With no impending complications
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YOU