CASE PRESENTATION

PAEDIATRICS
GAUTHAM KUMAR
ROLL NO:33
 CASE SHEET
 NAME:Harikrishnan
 AGE:10 Years
 SEX:Male
 Residence:kk nagar
 Informant:Mother
 Realiability:Good
 CHIEF COMPLAINTS
 Fever for past 5 days.
 Vomiting and loose stools for past 2 days.
 Rashes over face and decreased urine output for the past 12 hours.

 HISTORY OF PRESENTING ILLNESS

 The child was apparently normal till 5 days back ,has been brought with c/o fever for the past 5
days which was sudden in onset,low grade,intermittent in nature.
 Not associated with chills or rigors
 No diurnal variation
 Complaint of vomiting for the past 2 days
 2 -3 episodes per day
 Vomits few minutes after food intake
 Vomitus contains undigested food particles
 Non bilious,not blood stained,non projectile,not associated with abdominal pain and headache.
 Complaint of loose stool for past 2 days
 3-4 episodes per day
 Watery in consistency
 Not mixed with mucus or blood
 Complaint of rashes over face for past 12 hours
 Flat ,rose coloured maculopapular rash ,not itchy.

 No history of dysuria/loin pain,yellowish discolouration of eyes,high coloured

urine,bonepain,bleeding,joint pain,cough with sputum.
 No history of weight loss or appetite,throat pain/ear discharge,altered sensorium/Seizures.
 No history of drug intake.
 PAST HISTORY
 No H/o similar illness,no h/o recent travel, h/o intake of outside food
 CONTACT HISTORY
 No h/o contact with open case of tuberculosis
 DEVELOPMENTAL HISTORY
 Appropriate for the age
 No developmental delay
 IMMUNIZATION HISTORY
 Immunized appropriate for age according to National Immunization Schedule
 BCG scar present
 FAMILY HISTORY
 No h/o similar illness
 NUTRITIONAL HISTORY
 Calorie intake:1570kcal,Expected:1690kcal,Calorie deficit:120kcal
 Protein intake :35g,Expected:37.5g,Protein deficit:2.5g
 SOCIOECONOMIC HISTORY
 Belongs of Lower Middle class according to Modified Kuppusamy scale

 SUMMARY
 10 year old male child admitted with fever of 5 days duration,vomiting and loose stools for 2
days duration ,rashes over face and decreased urine output for past 12 hours with calorie gap of
120kcals and protein gap of 2.5gms,immunized upto age
 GENERAL EXAMINATION
 Sick looking
 No H/O Pallor,icterus,cyanosis,clubbing,lymphadenopathy and pedal edema
 VITALS
 Pulse:92/min
 Regular in rhythm,normal volume ,no radio-radial or radio femoral delay
 Respiratory rate:18breaths/min regular,thoraco abdominal type of breathing
 Bloodpressure:98/60mmHG recorded on left upper limb in supine position.
 Temperature:100 degree faren heit measured in axilla
 ANTHROPOMETRY
 Weight:22kg
 Height:129cms
 BMI:13.5
 HEAD TO FOOT EXAMINATION
 Head size and shape normal
 Rashes present over the face
 Eyes:no pallor,no conjunctival discharge,no phlycten,no icterus
 Ear and nose: normal,no sinuses,no tenderness
 Oral cavity: coated tongue,no caries of tooth, no angular stomatitis,no bleeding gums,no tonsillar enlargment .
 No bruises
 No eschar
 No bone tenderness
 No joint swelling
 Genitals:no phimosis
 SYSTEMIC EXAMINATION
 ABDOMEN
 INSPECTION
 Abdomen not distended
 All quadrants move equally with respiration
 No scars,no sinuses,no dilated veins,visible pulsations,peristalsis
 Umblicus:midline position,inverted
 No visible mass
 PALPATION
 Superficial palpation:no warmth and tenderness
 Deep palpation:
 Liver : palpable 2.5 cm below the right costal margin,not tender,soft in consistency,smooth
rounded edge,moves with respiration
 Spleen :palpable 3 cm below left costal margin,firm in consistency,non tender,moves with
respiration.
PERCUSSION
Liver span:11.5cm
Puddle sign:negative
No free fluid in the abdomen
AUSCULTATION
Bowel sound 6 per minute auscultated in right iliac fossa
No bruit
 CVS
 S1 S2 heart sounds heard normally
 No murmurs
 RS
 Bilateral air entry ,normal vesicular breath sounds heard,no added sounds
 CNS
 No focal neurological deficits
 SUMMARY
 10 year old male child admitted for acute onset of fever, vomiting, loose stools , rashes and
hepatosplenomegaly,differential diagnosis would be,
 Enteric fever
 Dengue fever
 Rubella
 CMV
 Malaria
 Kala azar
 Infectious mononucleosis
 Leptospirosis
 INVESTIGATIONS
 CBC
 DC
 HBS
 PERIPHERAL SMEAR;Malarial parasite
 MP-QBC
 WIDAL TEST
 DENGUE SEROLOGY
 Urine culture and sensitivity
 IGM
 Mantoux
 Bone marrow examination
 USG
THANK YOU