PAEDIATRIC PATIENT CASE HISTORY

Name: Vigenia Erasto

Age: 2 years and 5 months old
Sex: female
Tribe:bena
Religion: Christian
Address: Mjimwema
Next of kin: her biological mother
Date of admission: 30/4/2018
Number of days in the ward: 1 day
Date of taking history: 1/5/2018

MAIN COMPLAIN
Diarrhea for 1 day
Fever for 1 day

HISTORY OF PRESENTING ILLNESS

Seen the patient in the paediatric ward who came with the complain of
diarrheoa and fever for 1 day. Diarrhoea was of suddenly onset,
increased in severity as time goes. Stool was of waterly in nature, Large
in amount, not blood stained, no foul smelling, mucoid in nature, of four
motion in 24 hours(per day).no history of difficult in swallowing, no
history of abdominal discomfort, no history of vomiting, there is history
of loss of appetite.no history of crying during micturition, no blood in
urine, no history of increase frequency in micturation.

Also the patient has the history of fever of gradual onset on and
off, relieved by taking paracetamol, get worsening at night,no history ear
discharge, no history of nose discharge, no history of loss of
consciousness, no history of convulsion, no history of blurred vision, no
history of chest discomfort, no history of chest tightness, no history of
difficulty in breathing, no history of cough, no history of lower limb
swelling.no history of joint pain, no history of change in mobility, no
history of joint swelling.Exclusive breastfeeding to the child was for 6
months and food preparation is not under good condition, and child
breastfeeded nine times per day and now child is drinking porridge and
eating ugali. The child has been given all immunization except measles
vaccine which will be given at 18 months of her age according to
Expanded program of immunization (EPI).There is history of using
mosquito treated net, no history of travelling to the malaria endemic
region. on admission the child was given intravenous(IV)medication and
blood sample was taken to the child for investigation and MRDT test
was negative..
REVIEW OF OTHER SYSTEMS
As per history of presenting illness.
PAST MEDICAL HISTORY
This is the first admission.no history of chronic illness such as diabetic
mellitus,tuberculosis,epilepsy and bronchial asthma.no known history of
foods and drugs allergya.no history of surgery.
ANTENATAL HISTORY
Booking was when the mother had a pregnant of 4 months.she visited 3
times.the mother was given haematenics which were ferrous sulphate
and folic acid als was given mebendazole and sulphadoxine
pyremethamine as intermittent preventive treatment.the mother tested
for HIV/AIDS and Syphilis and the results were negative and non
reactive respectively.no any complication developed to the mother
during pregnancy.
NATAL HISTORY
A baby girl was born with 3.2kg at ikeru mission hospital,full term baby
by caesarean section,a child cried soon after delivery as mother
reported,duration of labour was for 22 hours,and the baby was able to
suck within one hour post delivery.
POST NATAL HISTORY
No any diseases a child suffered after delivery such as yellowish
colouration of the skin and convulsion.And the cord dropped after five
days post delivery.
IMMUNIZATION HISTORY
Are as per history of presenting illness.
DIETARY HISTORY
Are as per history of presenting illness.
DEVELOPMENTAL MILESTONE
A child started to smile after 4 weeks, a child started to control her neck
after 4 months,a child started to sit without support after 4 months,a
child started to sit with support after 6 months.and the child started to
walks with support after 12 months ,started to walk without support after
15 months and now the child is able to run.
FAMILY AND SOCIAL HISTORY
The mother has only one kid,she lives with her husband,both parents are
form four leavers,and both are farmers,they are neither cigarrete
smoking nor alcohol takers,they live in well ventilated house.no history
of familial diseases like asthma,diabetic mellitus and epilepsy.
PHYSICAL EXAMINATION
GENERAL EXAMINATION
The child is ill looking,moderate wasted,cannulated on the left radial
vein,normal hair colour,texture and distribution.posterior fontanelle was
closed and anterior fontanelle and no jaundice per sclera,no pallor per
conjunctiva.no ear discharge,no nose discharge,no angular cheilitis,no
angular stomatitis,no central cyanosis,no oral thrush.no palpable
enlarged lympnodes,normal warmth of upper and lower extrimities,no
palmar pallor,no fungal nail infection,normal capillary refill,no finger
clubbing.no lower limbs oedema.
DEHYDRATION STATUS
The child has the following signs of dehydration are as follows;
--the child is lethargic
-child is able to drink well
-skin pinch goes back slowly
-no sunken eyes
Hence the child has some dehydration.
ANTHROPOMETRIC MEASUREMENTS
Body weight=11.9kg
Length=76cm
Occipital frontal circumference=47cm
MUAC=14cm
Weight for length=Median
VITAL SIGNS
Temperature=38.5°C
Pulse rate=100 beat per minute
Respiratory rate=37 breath per minute
Hence all vital signs are normal except temperature.
SYSTEMATIC EXAMINATION
PER ABDOMEN EXAMINATION
On inspection
-no surgical scars,no traditional marks,no any enlarged mass,abdomen
moves with respiration.
On auscultation
-three bowel sounds were heard in a one minute.
On palpation
-on superficial palpation no any tenderness,no any masses and on deep
palpation,liver and spleen were not palpable and kidney was not
ballotable.
On percussion
-tympanic note sound was heard.
CARDIOVASCULAR SYSTEM EXAMINATION
Pulse rate as per general examination of regular regular,strong
volume,synclonised with left femoral artery.no jugular vein distension.
ON PERICARDIAL AREA
On inspection
-no surgical scars,no traditional marks,no heart hyper paractivity.
On palpation
-no any tenderness on pericardial area,apex beat was located at 4 th
intercostal space along the left midclavicular line.
On auscultation
-first and second heart sound were heard with no any added sound.
RESPIRATORY SYSTEM
On inspection
-no surgical scars,no traditional marks,no any visible masses,chest
moves symmetrical with respiration.
On palpation
-trachea is centrally located,no any tenderness,there was bilateral equal
chest expansion.
On percussion
Resonant note sound was heard.
On auscultation
Normal vesicular breath sound wasw heard.
NERVOUS SYSTEM EXAMINATION.
CRANIAL NERVES
-the child was able to rotate the eye balls in all four plane.
-the child was able to smile symmetrical with facial expression.
-the child was able to hear rubbed fingers.
-uvula was centrally located.
Hence all tested cranial nerves were intact.
MOTOR PART
-No involuntary movement in both upper and lower limbs.
-normal muscles backness
SUMMARY
A 2 years and 5 months old female child from mjimwema came with the
complain of diarrhea and fever for 1 day.diarrhea of suddenly
onset,watery in nature,mucoid in nature,diarrhea of four motion per day
and fever was of gradual onset on and off,relieved by taking paracetamol
and increased in severity as time goes.on examination the child is
lethargic,no sunken eyes,the child was able to drink well and her skin
pinch goes back slowly.all vitals signs are normal except body
temperature which is febrile and MRDT was negative.
DIAGNOSIS
  ACUTE WATERY DIARRHOEA WITH SOME
DEHYDRATION.
Supportive features
-diarrhea for 1 day
-watery in nature
-diarrhea of four motion per day
-the child is lethargic
-the child was able to drink well.
-the skin pinch goes back slowly.
-the child has no sunken eyes
DDX
 AMOEBIC DYSENTRY
positive features of watery diarrhea but negative features of blood mixed
with the stools
 DIARRHOEA WITH SEVERE MALNUTRITION
With positive features of watery diarrhea but negative features of
absence of signs of severe acute malnutrition.
 DIARRHOEA ASSOCIATED WITH RECENT ANTIBIOTIC
USE
With positive features of diarrhea but negative feature of recent course
of broad spectrum oral antibiotics
 INTUSSUSCEPTION
 With positive features of diarrhea,watery stool mucoid in nature
but negative features of mixed with blood,abdominal mass and
attack of crying with pallor
 TYPHOID FEVER
Positive feature of diarrhea,fever,loss of appetite but negative
features of abdominal discomfort and headache
INVESTIGATION
 FULL BLOOD PICTURE FOR ELEVATED NEUTROPHILS
 STOOL ANALYSIS FOR AMOEBA PARASITE DETECTION
 HIV TEST-NON REACTIVE
 WIDAL TEST for typhoid fever

TREATMENTS
 The child should be given ORS 1200mls should be given in the
first 4 hours
 Paracetamol tablets 180mg PRN eight hourly for 3 days.
 Paed zinc 20mg once daily for 2 weeks.
 And the mother should continue feeding the child with a lot of
foods rich in fluid her child

PREVENTION
 Continue feeding the child with a lot of foods like fruits
 Personal hygiene to whole family
 Early diagnosis and treatment of diarrhea to the children
 Immunization to the child is very important