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    Case Presentation: Moderator-Dr. Radhamohan Rana Presenter - Dr. Aakash Yadav

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    Rajan Dutta
    This case presentation is for a 6-month-old female child named Divya who has been experiencing fever, loose stool, and vomiting for the past 10 days. Her mother notes she had diarrhea 8-10 times per day with watery yellow stool but no blood or mucus. She was previously admitted for acute gastroenteritis and mild anemia. On physical exam she appears dull and irritable with a heart rate of 106 bpm, respiratory rate of 28, and is underweight and stunted for her age. She is being treated with antibiotics and her symptoms of diarrhea and vomiting have improved but not fully resolved.

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    Case Presentation: Moderator-Dr. Radhamohan Rana Presenter - Dr. Aakash Yadav

    Uploaded by

    Rajan Dutta
    31 views13 pages
    This case presentation is for a 6-month-old female child named Divya who has been experiencing fever, loose stool, and vomiting for the past 10 days. Her mother notes she had diarrhea 8-10 times per day with watery yellow stool but no blood or mucus. She was previously admitted for acute gastroenteritis and mild anemia. On physical exam she appears dull and irritable with a heart rate of 106 bpm, respiratory rate of 28, and is underweight and stunted for her age. She is being treated with antibiotics and her symptoms of diarrhea and vomiting have improved but not fully resolved.

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    Aakash

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    This case presentation is for a 6-month-old female child named Divya who has been experiencing fever, loose stool, and vomiting for the past 10 days. Her mother notes she had diarrhea 8-10 times per day with watery yellow stool but no blood or mucus. She was previously admitted for acute gastroenteritis and mild anemia. On physical exam she appears dull and irritable with a heart rate of 106 bpm, respiratory rate of 28, and is underweight and stunted for her age. She is being treated with antibiotics and her symptoms of diarrhea and vomiting have improved but not fully resolved.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    31 views13 pages

    Case Presentation: Moderator-Dr. Radhamohan Rana Presenter - Dr. Aakash Yadav

    Uploaded by

    Rajan Dutta
    This case presentation is for a 6-month-old female child named Divya who has been experiencing fever, loose stool, and vomiting for the past 10 days. Her mother notes she had diarrhea 8-10 times per day with watery yellow stool but no blood or mucus. She was previously admitted for acute gastroenteritis and mild anemia. On physical exam she appears dull and irritable with a heart rate of 106 bpm, respiratory rate of 28, and is underweight and stunted for her age. She is being treated with antibiotics and her symptoms of diarrhea and vomiting have improved but not fully resolved.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    of 13

    CASE PRESENTATION

    Moderator- Dr. Radhamohan Rana


    Presenter- Dr. Aakash Yadav
    Basic information
    • Name- Divya
    • Age – 6month
    • Sex- female
    • Place of residence – lath, Sonipat, Haryana
    • Informant- Mother (reliable)
    PRESENTING COMPLAINTS
    • FEVER FROM 10 DAYS
    • LOOSE STOOL FROM 10 DAYS
    • VOMITING FROM 10 DAYS
    HISTORY OF PRESENTING
    COMPLAINTS
    • Mother told that child was apparently well 10 days before. Then she had
    fever from last 10 days , fever was low grade , intermittent .fever subsided
    with syp Pcm for few hours. Fever was not associated with chills and rigor. Pt
    had diarrhea from last 10 days , 8-10 episodes perday . Stools were watery in
    consistency , yellow colored . Stool were large volume , not foul
    smelling .stools were not associated with passage of blood or mucous in
    stool. There is no history of past laxative use. There were no presence of
    worms in stool. Diarrhea was associated with fever and vomiting. Pt had
    vomiting from last 2 days 3-4 episode per day. Vomiting was non projectile .
    Content of vomitus was milk. There is no history of abdominal distention ,
    altered sensorium. There is no history of decreased urinary output . There is
    no history of drug use whose complication may predispose for diarrhea.
    • Pt was admitted on 9/6 and was treated with antibiotics after which
    frequency and volume of stools has been decreased , there is no
    episode on vomiting from last 6 days, there is no fever episode in last
    5 days
    Past history
    • Pt was admitted in pediatrics ward of our hospital from 20/05 to
    29/05 with AGE with some dehydration/mild anemia. For which pt
    was investigated and managed conservatively and discharged on
    • Syp.zinc
    • WHO ors
    • There is no history of prior blood tranfusion
    • Antenatal history- pt’s mother was well in all trimester ,
    vaccinated.Mother age at time of birth was 24 years. G3P3. there is
    no history of prior abortion or still birth. There is no history of any
    infectious disease or rash during pregnancy. Mother was given
    prophylactic iron and folic acid from 2nd trimester onwards
    • Birth history- ftnvd in hospital / AGA/ CIAB/NO HISTORY OF CYANOSIS
    OR BLUISH DISCOLORARTION
    DEVOLPMENTAL HISTORY
    • Social- stranger anxiety (DQ=1)
    • Language- speak in monosyllables(DQ=1)
    • Fine motor-reaches out for objects with one hand(DQ=1)
    • Gross motor- sites with support(DQ=1)
    NUTRITIONAL HISTORY
    • EBF FOR 2 MONTHS
    • Top feed buffalo milk with half water after 2 month of age
    • There is no history of pre-lactational feed.
    Immunization history
    • Immunised till date as per NIS
    FAMILY HISTORY
    • Age of parents at birth mother-24, father-27
    • Non consanguinity marriage
    • Lower middle class family, lives in pakka house.
    Physical examination
    • General appearance-concious, GCS-15, pt is dull and irritable, lying
    down
    • Vitals- HR-106 bpm,RR- 28 pm, temperature- 98.6 f,
    • ANTROPOMETRY
    • Weight – 4.160
    • HC- 38cm height for age – z score -3
    • CC- 37 cm weight for age -3
    • Length- 58cm weight for height -3
    • Pallor +
    • Cyanosis-
    • Jaundice-
    • Clubbing-
    • Lymphadenopathy -

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