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: 23^rd September 2015 to ER @ 2:00pm

Date of Examination: 24^th 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 : 38^oC

Anthropometry

Length:  74cm, which lies between the 10^th  and 25^th centile.

HC (head circumferene): 46 cm lies between the 10^th and 25^th 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