2 year old male child with fever,abdominal pain
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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 general medicine opd with CHEIF 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
Heart rate: 74 bpm
Respiratory rate: 14 cpm
Blood pressure: 120/70 mmHg
Pulse: Normal rate and rhythm
FEVER CHART :
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
INVESTIAGATION:
ULTRASOUND
BACTERIAL CULTURE AND SENSITIVITY:
COMPLETE BLOOD PICTURE:
CHEST AND ABDOMEN XRAY PA VIEW:
TREATMENT:
Iv Fluids and Paracetamol
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