2 year old male child with fever,abdominal pain

 PREFINAL PRACTICAL EXAMINATION

HARTHIK CHOPPA

ROLL NO 56

This is an online e log book to discuss our patient de-identified health data shared after taking his / her / guardians signed informed consent. Here we discuss our individual patients problems through series of inputs from available global online community of experts with an aim to solve those patients clinical problem with collective current best evident based input.

This E blog also reflects my patient centered online learning portfolio and your valuable inputs on the comment box is welcome.

I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

The patient details were given by his mother

A 2 and a half year old male child resident of miryalaguda came to opd with chief complaints of:-

1) Fever since 2 days

2) Pain abdomen since 1 day

HISTORY OF PRESENTING ILLNESS

Patient was apparently asymptomatic 2 days back then he developed fever which was sudden in onset, intermittent.

Not associated with chills, cold, cough.

No known aggravating factors and relieved on medication

Later on he developed pain abdomen gradual in onset, non progressive, diffuse type

No known associated aggravating and relieving factors

No h/o vomiting, loose stools

No H/o outside food, travel history

No H/o burning micturition

No H/o Rash

No H/o Rapid breathing, cold, cough

No H/o PICA, worm in stools

PAST HISTORY

Not a known case of TB, epilepsy, Hypertension, Diabetes mellitus, Asthma.

IMMUNIZATION HISTORY

Immunization on track

DEVELOPMENTAL HISTORY

All milestones attained as per age. No developmental delay

PERSONAL HISTORY

Diet: Mixed

Apetite: Normal

Bowel and Bladder movements: Normal

Sleep: Normal

No addictions

FAMILY HISTORY

No significant family history

GENERAL EXAMINATION

Patient is conscious, coherent and cooperative

Moderately built and nourished

No pallor, icterus, clubbing, cyanosis, lymphadenopathy and edema



VITALS

Temp: 98.7

FEVER CHART


Heart rate: 74 bpm

Respiratory rate: 14 cpm

Blood pressure: 120/70 mmHg

Pulse: Normal rate and rhythm

SYSTEMIC EXAMINATION

PER ABDOMEN

Inspection:- 

Shape of abdomen normal

Umbilicus central and oval in shape

No scars, sinuses, engorged veins

All quadrants moving equally with respiration

No visible pulsations

Palpation:-

All inspectory findings are confirmed with palpation.

Soft, non tender, no organomegaly, no rigidity

Percussion:-

No fluid thrill

Auscultation:-

Bowel sounds heard

RESPIRATORY SYSTEM

Inspection:-

Trachea central in position

No scars sinuses engorged veins

Shape of chest normal

Palpation:-

Bilateral symmetrical expansion of chest

All inspectory findings confirmed on palpation

Auscultation:-

Normal vesicular breath sounds heard on both sides lungs clear

CARDIOVASCULAR SYSTEM:-

Inspection:-

No scars sinuses engorged veins

Palpation:-

Apex beat felt at 5th intercoastal space

Auscultation:-

S1, S2 heard, no murmurs

CENTRAL NERVOUS SYSTEM:-

Child is conscious, coherent, well oriented to parents

Cranial nerves intact

Sensory system normal

Motor system tone, power and bulk normal on all four limbs


PROVISIONAL DIAGNOSIS:-

Fever and abdominal pain under evaluation, Gall bladder sludge under evaluation.

INVESTIGATIONS:-

ULTRASOUND



BACTERIAL CULTURE AND SENSITIVITY



COMPLETE BLOOD PICTURE



CHEST AND ABDOMEN XRAY PA VIEW


TREATMENT:-
NBM
IV Fluids
Paracetamol





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