Case Presentation
Presented by:
Dr Qurat Ul Ain
Dr Farhana Akter
Popy
Particular of the patient
Name: Md. Yusuf
Age: 2 Yrs
Sex: M
Religion: Islam
Address: Shahidnagar, Lalbagh
DOA: 19-5-2025
DOE: 19-5-2025
Informer: Mother
Chief Complaints
1. Fever for 2 days
2. Generalized body rash for 1
day
3. Constipation for 2 days
History of presenting illness
According to the statement of the patient`s mother, he was reasonably
well 2 days back . Then he developed fever for 2 days, which was
continuous in nature, not associated with chills & rigor. His highest
temperature recorded was 103 degrees F, temperature was subsided by
taking antipyretics. He has no travelling history in any endemic areas.
He also has complaints of rashes all over the body for 10 days, which
was small in size, red in color, started from trunk & then became
generalized. Rashes then subsided simultaneously. He also complained
of constipation for 2 days. On questioning, she complaints that the baby
cries during micturition and increased frequency of micturition for
several months. With these complaints, he was admitted to this hospital
for better management.
History of past illness
1. H/O: Pneumonia
Birth History
• Antenatal History: His mother is 2nd
gravida & was on regular antenatal
checkup and took 3 doses of tetanus
toxoid during pregnancy.
• Intra natal History: He was born at term
by LUCS without any prenatal complaints.
• Post natal History: He cried immediately
after birth. His birth weight was 3 kg.
Immunization history
The patient is well immunized according to EPI
schedule
Feeding History
He was on exclusive
breastfeeding up to 6 months of
age and then started
complementary feeding along
with breastfeeding after 6
months.
Developmental History
His milestone of
development is age
appropriate.
Drug history
Paracetamol
Drugs for pneumonia which
his mother could not
mention
He has no hypersensitivity rxn
to any drugs
Family History
He is the 2nd issue of non-
consanguineous parents.
His sister has hypothyroidism
Other family members are in
good health
Socio-economic history
He belongs to a middle-class
family
Lives in a building, drinks
boiled water.
Personal History
No significant personal
history
General examination
Appearance: ill looking
Body built: Average
Cooperation: Cooperative
Decubitus: On choice
Nutrition: average
Anemia: Mildly anemic
Jaundice: Absent
Oedema: Absent
Dehydration: Absent
Clubbing: Absent
General examination
Koilonychia: Absent
Leukonychia: Absent
Pulse: 89 beats/min
BP: 110/70 mm of Hg
RR: 32 b/min
Temperature: 98ºF
Neck vein: Not engorged
Lymph node: Not palpable
Skin examination: Rashes
Tongue: Coated
BCG Mark: Present on left arm
Anthropometry: 1. Height: 88 cm [Link].1kg/m2
[Link].3kg 4. Occipito frontal
Systemic examination
Abdominal examination :
Inspection:-
Shape and size of abdomen is normal.
Umbilicus is centrally placed and inverted
No visible mass, distension, scars, dilated veins or peristalsis.
Palpation:-
• Temperature is normal
• No tenderness
No organomegaly
Percussion:-
• Not done
Auscultation:-
Bowel sound is present, on right mid spinoumbilical line
Systemic examination
-Respiratory system
Inspection:-
Chest is bilaterally symmetrical.
Chest movements are normal
No visible scars, deformities or dilated veins.
Hair distribution is normal
Palpation:-
Trachea is centrally placed.
Apex beat is located in 5th ICS
Vocal fremitus is normal
Chest expansibility is normal
Percussion:-
• Not done .
Auscultation:-
Vesicular breath sound
No added sound
Systemic examination
- Cardiovascular System
Inspection:-
The chest is bilaterally symmetrical
No visible scars or deformities
No abnormal or visible pulsation
Palpation:-
Apex beat is palpable in fifth intercoastal space
Percussion:-
Not done
Auscultation:-
First and second heart sound audible in all 4 areas
No added sound or murmur
Systemic examination
Nervous system : -
Patient was conscious, oriented and cooperative, with no
neurological deficits
Other examinations had no significant findings.
Salient features
Md. Yusuf, 2 years old, hailing from Shahidnagar, Lalbagh, admitted to this hospital with the complaints
of fever for 2 days, generalized body rash for 1 day, constipation for 2 days, According to the
statement of the patient`s mother, he was reasonably well 2 days back . Then he developed fever for 2
days, which was continuous in nature, not associated with chills & rigor. His highest temperature
recorded was 103 degrees F, temperature was subsided by taking antipyretics. He has no travelling
history in any endemic areas. He also has complaints of rashes all over the body foe 10 days, which
was small in size, red in color, started from trunk & then became generalized. Rashes then subsided
simultaneously. He also complained of constipation for 2 days. On questioning, she complaints of the
bay crying during micturition and increased frequency of micturition for several months. He has past
history of Pneumonia. On general examination, he is normal looking, average body built, co-operative.
He is mildly anaemic, non icteric, non-dehydrated, BCG mark present. Pulse is 98 bpm, BP is 110/7 mm
of Hg, RR: 32B/min., temperature: 98 degree F, Height:88cm, weight: 12.3kg, OFC: 45CM, BMI:15.1
kg/m2 . On systemic examination, the shape and size of abdomen are normal, umbilicus is centrally
placed and inverted, no scar marks are present. On palpation, no tenderness, no organomegally.
Furthermore, on auscultation, bowel sound were present in the right mid spinoumbilical line. With these
complaints, he was admitted in this hospital for better management.
Provisional Diagnosis
Enteric fever with urinary tract
infection
Differential Diagnosis
Enteric
fever with Dengue
UTI fever
Viral Fever Measles
Investigation
1. Complete blood count:-
On 19-05-25:-
Hb% = 7.5gm/dl
WBC = 5000/cmm
Platelets = 390000/ cmm
HCT = 24.90%
MCV= 56.10 fL
MCH= 16.90 pg
MCHC= 30.20 g/dL
2. Urine R/M/E:
• Pus cells= 6-10/ HPF
3. Febrile antigen:
• Widal Test: TO: 1:160
4. Dengue NS1 : -VE
Investigation
Investigation
Investigation
Clinical Diagnosis
Enteric Fever
with Urinary Tract
Infection
Diet: Normal Treatment
Inf. Neosol DS (500ml)
IV @ 20d/min.
Inj. Topcef (ceftriaxone)
1gm___ OD
Inj. V-Plex (vit. B complex)
Syp Bilanex (bilastine)
4ml____OD
Syp Napa
1 ½ TSF____4 hrly (If temp. is >100 degree F
• Supp. Napa (if the temp. is >100gegree F)
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