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Theertha Dinesh 139
Biodata
NAME - Baby of Lubna
AGE - 5 weeks 4 days ( DOB- 25/5/2025)
SEX - male
MRD NUMBER - 2868475
PLACE - Malapuram
INFORMANT - mother (reliable)
DATE OF ADMISSION - 27/6/2025
DATE OF EXAMINATION - 3/7/2025
Chief complaints
Presented with ℅ weight loss after birth
Vomiting x 1 week
History of presenting illness
Baby of Lubna 1month old male child, weighed 3.75 at birth. The weight reduced
to 3kg within 3 weeks.
Vomiting during 4th week of birth , curdy white in colour, with tinge of sputum,
varies in amount , more in mornings and nights. Aggregation factor - right after
breastfeeding. Vomit expelled from mouth as well as the nose.
No fever, altered sensorium of seizures, constipation or loose stools
Past history
History of admission on 25th June 2025 due to failure to thrive
No surgical history
No history of vaccines taken
No history of contact with sick members
Birth history
1st child of non consanguinous marriage (married since 3 yrs)
No history of congenital birth defects / still births / abortions
Father and mother blood group - O+ve
Mother diagnosed with fibroid 1cm at the age of 27
Antenatal history
Spontaneous conception
Pregnancy confirmed by UPT test 6 days after missing periods
Age of mother at time of pregnancy - 27
Regular antenatal checkup done
1st trimester - folic acid was started soon after the confirmation of pregnancy
Dating scan was done
No history of fever with rash ( TORCH infections )
No history of hyperemesis
No drug / radiation exposure
No history of spotting / bleeding
2nd trimester - Iron and calcium was started
Anomaly scan showed no abnormalities
Quickening was felt
2 doses of TT taken
No history of GDM , UTI , bleeding , pregnancy induced hypertension
(5th month) - fibroid x 5cm
3rd trimester- iron and calcium continued
Adequate fetal movements felt
Pre pregnancy weight = 47 kg Weight gain = 12 kg
28 weeks - mother diagnosed with hepatitis A manifested as fever,
Vomiting and diarrhoea
32 weeks - fibroid x reduced to 2cm
35 weeks - growth scan showed hydronephrosis with hydroureter
in fetus
Natal history
Term baby
C section ( indication - no pain even after induction )
Child cried soon after birth
Birth weight - 3.75 kg
Fibroid removed along with delivery
Post natal history
For 1hr after the delivery - admitted in NICU- due to respiratory distress
Breastfeeding started 1 hr after shifting from NICU
Additional formula milk given for 5 days due to decrease in the amount of breast milk
48 hrs after birth USG done showing bilateral hydronephrosis
on day 2 child underwent MCU showing grade 5 VUR and was started on antibiotics
Urine and meconium passed within 24 hrs
No history of jaundice and seizures
Developemental history
Child is active and alert. Responds to sounds
Dietary history
Exclusive breastfeeding till date
Immunization history
No vaccines have been taken till date
Family history
No h/o of kidney diseases in the family
No congenital anomalies
Socioeconomic history
Father- Jasim
Age - 31
Education - diploma
Occupation - engineer
Mother- lubna
Age -28
Education - PG chemistry
Housing -own
Appropriate ventilation
Water - well water
No pets
[Link] rooms - 3
Family members - 3
No overcrowding
No smokers in the family
General examination
The examination was conducted in a well lit, well ventilated room after taking
consent. The baby looked weak and tired.
Vital signs
Pulse- rate- 104 bpm
Rhythm- regular
Character-normal
Volume - adequate
Condition of vessel wall - soft and elastic
Blood pressure - not measured
Temperature - afebrile
Respiratory rate - 44/min
CRT- 1 sec
No pallor , icterus , cyanosis , clubbing , lymphadenopathy , edema
Head to foot examination
Head- round with no scars or lesions on face. No dysmorphic features
Eyes- evenly placed , equidistant from nose
Nose - in midline , nasal septum in midline , no discharge. No DNS
Ears- symmetrical and parallel. No discharge or lesions noted
Oral cavity -normal gums , tongue. No deviation of jaw nor of tongue. No lesions
noted
Neck - trachea appears central. No swellings
Chest- round and symmetrical, smooth contours . No scars , dilated veins
Abdomen - normal , umbilicus in midline. No scars, dilated veins or pulsations
seen
Limbs and spine - normal with no deformity
External genitalia - normal
Anthropometry
Category Expected Actual Comparison Interpretation
Weight(kg) 4.65 3.45 74% Grade 1PEM
Length (cm) 53 57 107% Normal
BMI(kg/m2) 16.6 10.6 63% Severe
malnourished
Head 36 33 91% Normal
circumference
(cm)
Systemic examination
GIT EXAMINATION
EXAMINATION OF ORAL CAVITY
lips- normal
Gums - normal
Tongue -normal, no redness
Oral mucosa - normal , pinkish color , no ulcers or bleeds
Palate - not seen
Tonsil- not seen
Pharynx - not seen
EXAMINATION OF LOWER GIT
INSPECTION
shape of abdomen -normal
Movement with respiration -bilateral , equal and symmetrical on both sides
Skin over abdomen - normal
Swelling in the epigastrium - non pulsating, bean shaped with well defined margins.
Umbilicus - normal midline position
Hernial orifices and external genitalia - appears normal
No dilated veins. No visible pulsation, peristalsis or visible mass
PALPATION
Feel of abdomen - soft and non tender. No guarding present
No local rise of temperature. No areas of warmth or tenderness.
Liver and spleen not palpable.
Renal, left - no palpable mass
Right - palpable , ballotable, smooth soft mass does not move with respiration
Swelling in the epigastrium - non pulsating, non reducible, bean shaped soft 1x1cm ,
soft in consistency, well defined margins and fixed to the skin
PERCUSSION - not performed
AUSCULTATION - bowel sounds - present
Soft bubbling type of sounds heard over lower quadrants
Central nervous system
Higher mental function -Appearance - tired looking , looks undernourished
Behavior- non irritable
Consciousness- conscious
Cranial nerve examination - not performed
Cardiovascular system
JVP - not observed
pulse - 104 bpm
Bp - not taken
Examination of precordium
Inspection - normal shape with bilateral symmetry
Apex beat not visible
Trachea appears central in position
No precordial bulge. No visible pulsations in the precordium. No dilated
veins or scars
PALPATION
Trachea appears central in position
Apex beat not palpable
No thrill. No palpable pulsations
PERCUSSION
RIGHT HEART BORDER- not percussed
LEFT HEART BORDER-no percussed
LEFT 2ND INTERCOSTAL SPACE-not percussed
AUSCULTATION
S1 and S2 heard over aortic, pulmonary, mitral , tricuspid areas auscultated
Respiratory system
EXAMINATION OF UPPER RESPIRATORY TRACT
ear- normal right and left ear. No discharge
Nose- no DNS. No discharge. No tenderness
Paranasal sinuses - no tenderness
Throat - not seen
EXAMINATION OF LOWER RESPIRATORY TRACT
INSPECTION
trachea appears central in position
Apex beat not visible
Shape of chest - normal in shape and bilaterally symmetrical
Movement of chest - all areas of both sides are symmetrical in movements
Respiratory movements - 44 breaths/min. Regular, abdominal respiration. No chest retraction. No scares,
swellings or dilated veins
PALPATION
trachea - central in position
Apex beat not palpable
Movement with respiration - bilateral equal and symmetrical on all areas
Chest expansion - not performed
PERCUSSION - not performed
AUSCULTATION - breath sounds normal , vesicular over the lungs. Air entry
bilaterally equal
No added sounds heard
SUMMARY
1 month old male presented with weight loss and episodes of vomiting. No
associated fever, altered sensorium, constipation. Antenatal scanning showed
bilateral hydronephrosis in the 9th month. No vaccines were given till date.
Vitals- pulse 44bpm,normal character,regular
On examination- right kidney was palpable showing a ballotable , smooth and soft
mass which does not move with respiration. A swelling was present in the
epigastrium which was non pulsating, non reducible, bean shaped,1x1cm, soft
consistency , well defined margins and fixed to the skin
DIAGNOSIS - bilateral hydronephrosis
Urinary tract infection
INVESTIGATION - urine culture
Ultrasound abdomen
Follow up
4/7/2025
IV antibiotics given
Repeated urine cultures given
5/7/2025
Abdominal USG done
IV antibiotics continued
Child was less irritated and had continuous sleep
Discharged on 7/7/2025
Thankyou