PAEDIATRIC CASE

PRESENTATION
PRESENTED BY:-
MODERATOR:-
Amit kumar (17)
DR. Ankita giri mam
Anupam Rawat (22)
(Assistant Professor)
Aparna painuly(23)
DEPARTMENT OF
Ayushi singh(24)
PAEDIATRICS
VCSGGIMS﹠R SRINAGAR
UTTARAKHAND
• CASE
• I’m presenting the case of Master nitin 7 yr. old
boy, Hindu by religion, resident of village
matkot , Gairsain chamoli , 2nd born to a non
consanguineous marriage to Mr. Kuldeep and
Mrs. Chandi devi . Child belongs to lower class
family according to modified BG Prasad scale.
• The history was taken on 5ᵗʰ jun 2024.
• Informant was Mother of the patient Mrs. Chandi
devi 29yrs old who is 8th pass and is a reliable
informant.
• The patient was admitted to HNB Base hospital
Srinagar on 30 May 2024.
• Chief Complaints:-
• Patient was presented to Paediatrics OPD
on 30 May with chief complaints of :
• Fever for 10 days
• Vomiting for 10 days
• headache 10 day
• History of present illness:-
• Patient was apparently asymptomatic 10 days back when he
developed
• Fever:
• gradual in onset,
• intermittent in nature,
• Mild intensity
• non-progressive
• non documented
• not associated with chills and rigor,
• no diurnal variation seen
• no aggravating factors
• fever was temporarily relieved by medication.
• Vomiting
• Child developed vomiting since 10 days
• sudden in onset
• frequency - 2 to 3 episodes/day
• yellowish in colour, watery in consistency, non billious,
non projectile,not blood stained,no foul smell
• content - undigested food particles
• not relieved by medication
• Headache
• Child also develop headache since 6 day which
was sudden in onset, non progressive in nature,
Severe in intensity, localised to frontal and
temporal region (non radiating)
• Partially relieved by medication
• No aggravating factor
• Not associated with blurring or watering of eyes
• Negative History
• No h/o any head trauma
• No h/o abnormal body movements.
• No h/o Ear discharge
• No h/o rash
• No h/o drug intake
• No h/o of food taken from outside
• No h/o of abdominal pain, swelling of abdomen
• No h/o of loose stool
• No h/o of cough
• No h/o neurological deficit
• Past history
• No h/o similar complaints in the past.
• No h/o TB
• No h/o any surgery
• No history of asthma
• Treatment history
• The child was taken to a local clinic on first day and was
given oral medication. to be taken thrice a day.
• Due to deterioration in gernal condition Child was treated
in CHC chamoli given iv medication for two days and on
30 may child was taken to hnb base hospital Srinagar
• He was put on iv medication
• Antenatal History
• Obs score G₂T₁P₀A₀L₀D₁
• Iˢᵗ order child was a full term baby,
delivered by normal vaginal delivery at
goverment hospital chamoli.
• Baby was healthy till 3ʳᵈ day when he
developed fever and was hospitalized for
the same.
• The baby died on 3ʳᵈ day itself.
• 1ˢᵗ Trimester
• It was second pregnancy which was confirmed by UPT
at one month and registered at PHC chamoli
• She went to hospital for 3 antenatal visits.
• USG was done on 3rd month
• Folic acid was taken.
• Routine blood and urine investigations were done and
found to be normal.
• No h/o excessive vomiting.
• No h/o radiation exposure.
• No h/o of alcohol, tobacco use, substance abuse
• No h/o polyuria, polydyspia
• No h/o burning micturition, increased frequency of
micturition,
• No h/o bleeding p/v.
• No h/o fever with rash.
• 2ⁿᵈ Trimester :-
• Quickening felt at 5ᵗʰ month of gestation.
• Iron folic acid and calcium were taken.
• Received 2 Td doses at 5th and 6th month.
• 2nd USG done in 6th month.
• No h/o Polyuria,polydyspia
• No h/o Bleeding per vaginum
• No h/o blurring of vision, headache, abdominal pain
• 3ʳᵈ Trimester:-
• History of fetal movements perceived.
• IFA and calcium tablets were taken
• USG done at 9 months ,growth on USG was found to be
normal as per mother.
• No h/o bleeding PV
• No h/o leaking PV
• No h/o Headache, Blurring of vision, Abdominal pain
• No h/o polyuria, polydypsia
• No h/o blood transfusion.
• Birth history:
• Birth order 2ⁿᵈ
• Full term normal vaginal delivery and
delivered at CHC chamoli
• Cried immediately after birth
• Birth weight 2.7kg.
• Gender =Male.
• No history of NICU admission
• Post natal history
• Breast feeding was initiated within half
hour of delivery.
• No history of abortion, still birth & IUD.
• Urine passed within 24 hours of birth.
• Meconium passed within 24 hours of birth.
• Personal History
• DIET:- mixed
• Sleep wake cycle:- normal
• Hygiene was maintained.
• No allergy to any drugs.
• No food allergy
FOOD Energy(kc Protein(g CARBOH Fat(gm) IRON(mg) Calcium(
ITEM al) m) YDRATE(g mg)
m)
Breakfast
1egg 80 2.5 16 0.3 0.9 6.25

Cow milk
100ml 146 6.4 9.8 8.8 0.4 3.125
Lunch
2Roti 160 5 32 0.6 1.8 12.50
25gm
1banana 110 1.5 25 0.5 0.5 10
Cow milk
100ml 73 3.2 4.9 4.4 0.2 120
Spinach 24 2 2.5 0.6 2.5 100
1/2 catori
2 roti 160 5 32 0.6 1.8 12.50
25gm
Total 680 22.4 118 12.2 8.1 240
RDA 1300 34gm 250 55 10 1000
Deficit 620kcal 11.6gm 132gm 42.8gm 2mg 760mg
• Developmental History
• All milestones were achieved on time
according to age and no
developmental delay seen,
development corresponds to
chronological age
• Gross motor : able to upstairs and
downstairs one foot or hopping
• Fine motor : able to draw
diamond/rhomboid
• Language milestone : tell story, 8 10
word sentence,knows telephone
number
• Social milestone : independent
dressing , bath independently
• Immunisation history:
• Child is immunised according to NIS upto age as per
mother.
• BCG mark was present over left upper arm.
• No documentation was provided by parents
• Last immunisation is at 5yr
• Family history
• No h/o consanguineous marriage.
• No history of similar episodes in family.
• No h/o of Koch’s contact in the family.
• No h/o congenital and genetic diseases in family
• Socioeconomic history
• Child belong to lower class family according to modified
B.G. Prasad scale
• 3rd generation family with 5 members.
• Family per capita income 1600
• Father is 10 and labour
• Mother is 8th passed and is housewife.
• Environmental history
• Family resides in a pucca house with 2 rooms separate
kitchen, seperate washroom, adequate ventilation
present in house water supply by nearby natural water
source(dhara) and stored in tank, 2 cattles, one dog in
house.
• Waste disposal by burning , no mosquito breeding
places nearby.
• Summary
• Master nitin 7 yr old, 2nd order child of non
consanguineous marriage belongs to upper lower class
according to modified B.G. prasad scale presented with
chief complaints of fever, vomiting, headache since 10
days admitted to paediatric ward on 30 may 2024 on
started iv medication symtoms are relieved,
Immunisation is completed as per NIS.
• The child is deficit in calories, protein, carbs, fat, iron and
calcium.
• D/D
• Bacterial meningitis
• Tb meningitis
• Encephalitis
• Stroke
• tuberculoma granuloma (ICSOL)
• Intra cranial hemorrhage