Introduction

Name :- Baby Upeksha Gender :- Female Age :6 months Address :- Habaraduwa D.O.A :- 06/08/08 History was taken from mother

Presenting complaint
Fever for two days Loose stools for 1 day

History of presenting complaint

Two days back child was apparently well. Then developed fever .It was a high grade fever . It associated with chills , but no rigors . Fever was not responded to paracetomol. With the fever , baby also had a mild dry cough. There was no sputum. Parents took the baby to a GP and took medicine. But the symptoms not resolved. Following day child developed loose stools. She passed watery stools for2 -3 times. And also she vomited 3 times . Stools and vomitus did not contain blood . On the evening of the second day of fever baby started to cry excessively and refused breast milk. Then parents consulted a pediatrician and he advised to admit the baby to the ward. On admission baby was having fever , dry cough and she was crying excessively. She was passing watery stools 4-5 times and vomiting 3 times. She did not have dysurea or haematurea. Her urine out put was good. There is no contact history of fever or diarrhoea at home.

Past medical history

For the last two months , baby was getting frequent episodes of upper respiratory tract infections. She got four episodes of URTI during last two months. Every time took medicine from a GP and symptoms settled with in 2-3 days with the treatment . There were no hospital admissions.

Birth history
It was a term , vaginal delivery. Birth weight was 2.935 kg . Baby cried after birth and breast feeding started with in hour.

No PBU care given.

Developmental history
Now the baby can sit without support, is having palmar grasp, can make sounds and smiles responsively.

Immunization history
BCG vaccine was given. 1st and 2nd doses of Hep. B , OPV and DPT given. Have to give 3rd dose of Hep. B,OPV and DPT.

Dietary history
Now baby is exclusively breast fed. Weaning food not started yet.

Family History
Non consanguineous parent.

35 yrs

14yrs

10yrs

8yrs

4 patient

No family history of Bronchial asthma.

Social history
Mother is a housewife and she has educated up to year ten. Father is a driver in UBR hotel,Unawattuna. Their monthly income is around 25,000 /= per month. They live in a separate house, with 04 living rooms. House situated in a non dusty area. There is no smoking at home and no mosquito coil use, They have 2 dogs and 1 cat at home. They use well borne water. Children use boiled ,cooled water . They have a water seal toilet.

Examination General
Weight 6.025kg (In between 3rd and 10th centiles ) Length 68cm. (In between 50th and 90th centiles) OFC 42cm (In between 10th and 50th centiles) Looking Well Active Afebrile Hydration is good CRFT < 2 seconds Not pale Not cyanosed No lymph node enlargement Baby is sucking well Ears ,nose ,throat are normal

Abdomen
Not distended. Anterior abdominal wall moves with respiration, No heptospleenomegaly. Bowel sounds present.

Respiratory system
Respiratory rate- 36 breaths per minute. There was no subcostal recessions. No accessory muscle use. Chest wall moves symmetrically. No chest wall deformities. On auscultation , air entry equal on both sides. Vesicular breathing. No added sound.

Cardiovascular system
Pulse rate : 120 bpm . Pulse regular and in good volume. S1 ,S2 hear with normal intensity. There were no murmurs.

Nervous system
Anterior fontanellae not tensed and could accommodate 2 fingers. Baby is moving her both upper limbs and lower limbs.

Summary
A 6 month old baby girl admitted to ward due to fever for 2 days and loose stools for 1 day. And also child had mild dry cough for these 2 days. This baby is getting frequent episodes of URTI for last two months. On examination child was looking well, Afebrile and hydration is good. Her respiratory , cardiovascular , abdomen and nervous system were normal.

Problems Medical
1) Fever followed by watery diarrhoea ,not blood stained. 2) Mild dry cough with no lung signs, suggesting URTI and she is getting frequent episodes of URTI.

Social
1)Prolonged hospital stay. Mother is with the child and there is nobody to look after other children.

Differential diagnosis
1) Acute viral gastroenteritis 2) Food poisoning 3) Lactose intolerance 4) UTI 5) Bacterial gastroenteritis (shigella,salmonellae , E coli) 6) Antibiotic induced diarrhoea

Discussion
My first differential diagnosis is acute viral gastroenteritis , because it is common and it gives rise to watery diarrhoea , fever and vomiting.

Even though I have considered about food poisoning , It is very unlikely because child is exclusively breast fed and not on any other foods. I consider lactose intolerance but on examination of stools and tests for reducing substances in stool, there was no positive findings. So I excluded lactose intolerance. There is no features suggestive of UTI in the history and UFR was normal. So can exclude the UTI. It cannot be the bacterial ,because there is no blood mixed with stools. And child was not on any antibiotic. So it can not be antibiotic induced diarrhea. Getting of frequent attacks of URTI is an another problem and on history there are no things supporting this, such as house is not over crowded ,it is non dusty ,no smoking at home ,no mosquito coils use at home and there is no family history of bronchial asthma. So need to follow up the child and if she is getting more episodes we should have to consider it seriously.

Acute gastroenteritis
Commonest cause is viruses 1) Rotavirus 2) Adeno virus 3) Calci virus 4) Corona virus 5) Astro virus Bacterial Eg: shigella Salmonellae E coli Dehydration and its complications are the usual cause of death in gastroenteritis and its correction is the fundamental aim of treatment.

Clinical factures of dehydration

Reduced level of consciousness Sunken fontanellae Eyes sunken and tearless Dry mucous membranes

Reduced tissue turgor Reduced capillary refill time Tachypnoea Tachycardia Hypotension Peripheral vasoconstriction Oliguria Sudden weight loss

Investigations
Stools full report Stool culture /ABST Other Ix for the DDs

Management
Correct dehydration IV access if not taking orally give fluids Monitor UOP Weight chart Antibiotics Notify (If blood and mucous diarrhoea)

Discharge
Should have Formed stools Stop defeacating in his sleep Not ill looking No vomiting Fever resolved Follow up In 1 week to the clinic