Wednesday, September 20, 2017

Sample History: Diarrhoea and vomiting in infant.

Sample Pediatric history writing : Vomiting and Diarrhoea

(This case is special to me because this history is digital version of the history
and clinical examination I presented in my ninth semester pediatrics board
examination. Most of the points are just jotted down which needs linguistic
description as you present them. The parenthesized and italic words are the way it
is said while the words that are just parenthesized are the justification in any
point where extra elaboration may be needed. Many points may be missing but I have
not corrected the things I have written in the exam sheet. Since this was a piece
of exam, so many points may be missing and complete elaboration is language is
absent. So I would like to apologize for that.)

Name: Ms. Pariyar

Age: 11months
Sex: Female
Address: Nala

Father: Mr. Pariyar, 23yrs Farmer,  Class 7

Mother: Mrs. Pariyar, 21yrs housewife, illiterate
Informant: Mother, hence reliable.


(Always write the level of education and profession of parents to know the level of
their comprehension and their approach to child health. The informant is important
as mother is the one who take cares of the child and knows the exact chronology and
series of event. While other informants such as father, grandparents are not the
first hand handler of the child and may only elaborate what they have been told by
the mother and may not know all the details.)

Date of admission: 23rd September 2015 to ER @ 2:00pm

Date of Examination: 24th September 2015

(Ms. Pariyar, 11yrs girl from Nala, daughter of Mr and Mrs pariyar was presented to
DH ER yesterday at 2:00 pm with complains of )

Chief Complaints
Vomiting for 5 hours x 1 day
                Diarrhoea for 1 day
(The history is given by mother, hence the history is reliable)

History of Present illness


According to the mother, the child was active and playful 2 days back, then she
developed 8-9 episodes of vomiting, which initially contained the ingested food
material (milk) and later turned greenish and watery. It was about 2 teaspoon full
in each episode, foul smelling and non-projectile.
After around 6 hours, the child developed diarrhea, 10-12 episodes/day, watery with
mucoid content, was foul smelling but did not contain blood in the stool. The child
cries while passing the stool but not during micturition.
There is also history of fever associated with diarrhea which was mild, continuous
and not associated with rash and abnormal body movement.
There is no loss of appetite, drinks vigorously. Mother gives history of infrequent
micturition compared to previous times.
No cough, no shortness of breath.
No loss of consciousness or avoidance of bright light.

Treatment history:
The patient was bought to DH 2 hours after the onset of vomiting, where she was
provided with IV medication which subsided the vomiting. The child has been
receiving IV fluids and the child is improving as vomiting has subsided but
diarrhea is yet to improve.

Past history

Birth
ANC: 6 ANC visits, taken folic acid, iron, calcium, 2 TT vaccines.
Natal: Cesarean delivery at DH for prolonged labor, cried immediately after birth,
passed stool and urine within 24 hours.
Post natal: breastfed within 24 hours of birth.
(The mother had regular ANC visits and had taken folic acid, iron, calcium and both
the TT vaccine. She underwent CS at DH for prolonged delivery. The child cried
immediately after birth, the child cried immediately after birth, passed stool and
urine within 24 hours. The child was breast fed within 24 hours of birth. The post
natal period was uneventful.)

(The child greater than 3 years all the prenatal, natal and postnatal history may
be uneventful and can be skipped without telling the minor details unless it has
significant relation to birth history. The child is breast =fed generally within 1
hour of birth but since this a CS case, so the breastfeeding may have been
delayed.)

Immunization
At birth BCG
6 weeks Hep B, Hib, DPT, OPV, PCV
10 weeks Hep B, Hib, DPT, OPV, PCV
14 weeks 2 vaccines Hep B, Hib, DPT, OPV, IPV (2 vaccine is the description given
by mother, Pentavalent in one vaccine and IPV in the next)
9 months MR + PCV
12 months and 15 months remaining.
(The child has received the vaccination as per the National EPI Schedule for her
age, the vaccinations of 12 months and 15 months are remaining.)

(All the vaccine mentioned need not be read one by one, rather National EPI
Schedule includes all. Mother can describe at what age, how many shots of vaccine
and oral drops the child has received. Based upon that we can confirm If the child
has received the necessary vaccination or not.)

Nutrition
                Exclusively Breastfed for 1 month
                Then added powder milk
                After 3 months: Sarbottam pitho
Currently Breastfed every 1-2 hourly for 10-15 minutes
Dal + rice small bowel 100X2 gm = 200 gm calorie: 260 kcal
Snack Biscuit 3 pieces 3x 20 = 60kcal
Total 340 kcal
8 kg 800 kcal  
(The child was exclusively breastfed for 1 months and then weaned with powder milk.
After 3 months of age sarbottam pitho was added to her diet. Currently she is
breastfed every 1-2 hour for duration of 10-15 minutes. Besides she is fed with 2
small bowel of regular meals and 3 pieces of biscuit in snack. The total calorie
intake besides breast milk is 340 kcal and the expected calorie intake needed is
800kcal)

(Calorie deficit can not be commented upon as the chold is still feeding on milk.
If breast milk does not form the significant source, the calorie defecit must be
calculated)

 
Development
Stands with support and walks with support (Motor)
Pincher grasp present (Fine Motor)
Uses bisyallable words and says baba and ama (language)
Interacts with mother (Social)

Past History

No history of similar illness in the past.

No chronic illness like asthma.

Family history
Mother had similar illness 1 week back.
No history of chronic illness.
(Pedigree drwaing is must in pedia, see the image) 

Socioeconomic history
Belongs to a well sustained middle class family.
Has provision of sanitary latrine and uses soap.
Drinks water from tap and spring water but does not boil the water.

Drug and Allergy history: Not present

History of Consanguinity: Not present
History of Contact to TB: Absent

Examination

Ill looking, fairly built child, is lying in supine position with yellow IV cannula
with fluid flowing through the cannula.

Vitals
Pulse: 136bpm, regular euvolemic
BP: (not feasible)
RR: 47bpm , regular, thoracoabdominal
Temperature : 38oC

Anthropometry
Length:  74cm, which lies between the 10th  and 25th centile.
HC (head circumferene): 46 cm lies between the 10th and 25th centile
Weight: 8 kg
MUAC : 14cm (Mid Upper Arm circumference)

(The anthropometry data are plotted in a standard growth chart and the centile is
measured or the expected values of various can be measured using various formula
and the percentage of the expected and the observed can be calculated.)

>>Learn normal anthropometry values and formula to calculate them in pediatric.

Head to Toe examination

Hair looks normal in color and texture.
Fontanels are not sunken.
No discharge and redness of eyes
No dryness of eyes or sunken eyes
No nasal discharge and congestion
Mouth and oral cavity looks normal with 2 lower incisors and 1 upper incisors
Skin surface looks normal
No icterus, pallor or cyanosis.
Hydration status looks normal.

Abdominal examination
On inspection

The abdomen is protuberant and the umbilicus is centrally placed. All quadrants
moving correspondingly with respiration. No visible pulsation, peristalsis or scar
marks.
All quadrant moving corresponding with respiration.
Hernial orifices intact.
Perianal erythema present.

On palpation
Abdomen is soft, non tender and no local rise in temperature.
On superficial palpation, no masses palpable.
Liver is palpable 2 cm from the right costal margin which is soft, non tender and
the margin is regular.
Spleen is not palpable and kidneys are not ballotable.

Kidneys are not ballotable.

On percussion, normal tympanic note is present all over the abdomen

On auscultation, normal bowel sound heard with 3 bowel sound/minute heard.

Chest: B/L equal air entry with normal vesicular breathe sound (NVBS).  S1S2M0
CNS/MSK: Grossly intact

Provisional diagnosis:   Acute Gastroenteritis

Differential Diagnoses:                 Enteric Fever
                                                Viral Hepatitis

                                                Secretory Diarrhoea