Diarrhoea case presentation

A Simple case diarrhoeA presented at under 5 clinic at SKIMS.

1. Case presentation Presenter: Dr. Walied K Balwan Moderated by : Dr Rauf-Ur Rashid Kaul Department of Community Medicine SKIMS,Srinagar .

2. CASE SUMMARY: Name: Tabindah Age : 3 ½ years Birth order : Ist R/o : Manigam , Ganderbal Religion: muslim Habitation; Rural Belonging to : Joint family of 5 members Informant: father

3. SOCIOECONOMIC STATUS: Income : Rs 5000 per month Education (HOF): 8 th class Occupation (HOF): Skilled worker S.E Class: Lower middle class as per B G Prasad classification 2014

4. Chief complaints: Loose stools 5-6 episodes * 1day. Pain in the abdomen Nausea* 1 day

5. History of present illness: As per pt.’s informant the child was in usual state of health 1 day back when she started with pain in the abdomen with an episode of loose stools during the day. Followed by loose stools 5-6 episode in 2-3 hours with nausea . Pain was colicky in nature involving whole abdomen

6. NO H/O: Vomiting, blood in stools, Fever, Refusal to feeds, Drowsiness, Convulsions, irritability, decreased urine output. Past history: Not significant.

7. Perinatal / Birth history: Type of delivery: NVD Place of delivery: SKIMS Birth weight: 3kgs Antenatal history : Mother received ANC from the SKIMS only. Immunized against T.T., received iron-folic acid supplementation and used to go for antenatal visits regularly. The antenatal period was uneventful.

8. Feeding history: Breast feeding started after birth and up to 8 months baby was exclusively breast fed. There is no H/O any prelacteal feeds. Frequency of breast feeding: on demand

9. Complementary feeding: It was started after 8 months with ¼ cup of mashed rice in milk,2 -3 biscuits with tea and ¼ of an egg and ¼ of a cup of cerelac . The frequency of complementary feeds were 2 to 3 times a day in addition to breast feeding which continued up to 2.5years.

10. Present diet: She is taking 1 home made chapati with 1 cup of salt tea in the morning and then at 11 o’clock ½ baked Roti with sugar tea and ¼ plate of rice with soup or mashed vegetables in the lunch, in the evening 1cup of salt tea with home made chapati and at dinner ¼ plate of rice sometimes vegetables. Some times fruits but not regular.

11. DIETARY ASSESSMENT OF CASE MEAL Food Item Consumption/day Calories (kcal) Proteins (gm) Carbohydrates (gm) Fats (gm) Iron (mg) Calcium (mg) Breakfast 8am 1 cup salt tea + 1 chapati 150ml 40 gm 33.5 136.4 1.6 4.84 2.2 27.6 2.05 .68 0.1 1.86 60 - 10 am 1 roti / 1 sugar tea 37 gm 150ml 128 50.5 4.5 1.605 26 7.17 .63 2.35 1.8 0.1 - 60 Lunch 2pm Rice 1/4cup + 1 bowl Cauliflower 37.5 gm 25gm 129.4 7.5 2.55 .65 29.3 1 .19 0.1 0.26 0.35 - 8.25 Banana (2 No) 232 2.4 54.4 0.6 0.72 20 Afternoon 5pm 1 cup salt tea + 1 chapati 150ml 40 gm 33.5 136.4 1.6 4.84 2.2 27.6 2.05 .68 0.1 1.86 60 - Dinner 9pm 1 /4 plate rice 37.5gm 129.4 2.55 29.3 .19 0.26 - TOTAL 1017 26.4 206.6 9.52 7.41 208.25

12. Calculation of Nutrient Requirements Energy requirement of case = CU x 2400 kcal = 0.5 x 2400 = 1200 kcal 12 Nutrient Percentage of total energy required Requirement (in gm) Protien 15 % = 180 kcal 45 gm Fat 20 % = 240 kcal 26.65 gm Carbohydrate 65 % = 780 kcal 195 gm

13. DAILY REQUIREMENT OF THE CASE KCAL CARB (GM) PROT (GM) FAT (GM) IRON (MG) CAL (MG) TOTAL DAILY REQUIREMENT {RDA} 1200 195 45 26.65 10 500 TOTAL CONSUMPTION 1017 206.6 26.4 9.52 7.41 208.25 DEFICIENT / EXCESS 183 ( D ) 11.6 ( E) 18.6 ( D ) 17.13 ( D) 2.60 ( D ) 291.75 ( D )

14. Developmental milestones : child has achieved all milestones at proper age till date. Motor development : was running here and there. Personal-social development: knows gender Adaptive development: ask for foods Language development: was able to speak simple sentences.

15. Immunization history: child is completely immunized as per EPI schedule. Socio-cultural history: practices of not giving certain foods during diarrhea is not present. Environmental history: the family resides in a single story house having 4 rooms and a lobby. kitchen is separate, separate washrooms with good drainage system and ventilation. Over crowding is absent.

16. Personal hygiene: satisfactory Health seeking behavior: They visit SKIMS hospital , district hospital Ganderbal for major and minor ailments.

17. Examination: Pt. is conscious, cooperative, oriented to time, place and person. WT: 14.5kgs HT: 96cms HC: 50 cms CC: 55cms MAC: 18 cms

18. THE child is having normal wt. /age: 14.5kgs (11.3 – 19.2kgs) as per WHO standards Ht. /Age: 96cms (89.8 – 105.7 cms ) normal as per WHO standards Wt. /Ht. % = Wt. of child/Wt. of a normal child at same ht. X 100 14.5/14.6 x1oo = 100% (>90%)

19. Vitals: Pulse: 86b/m R/R: 22 b/m Temp: 100 f B/P: not recorded GENERAL EXAMINATION: CONDITION: Conscious ,oriented, alert Eyes: Normal Feel: Skin Pinch Tongue: Moist (Goes back instantly) Thirst: Not thirsty

20. Head and face: Anterior fontanel: closed Pallor No Icterus odema Ear, Nose and Throat: Normal

21. Neck: No LAP Skin and Appendages: Normal Systemic Examination: Respiratory system: Inspection: Shape normal No abnormal breathing movements No chest in drawing Palpation: Normal Percussion: Normal

22. Auscultation: B/L air entry Normal, No added sounds, strider/wheeze CVS: S1, S2 heard, no added sounds Abdomen: Inspection: no scar or visible mass Palpation: no organomegaly Auscultation: Bowel sounds heard

23. Diagnosis: DIARRHOEA WITH NO DEHYDRATION

24. Diagnosis: DIARRHOEA WITH NO DEHYDRATION

25. Treatment: ORS Zinc Probiotic Advice Given: At individual level: Advice on increased dietary intake to meet the demands of growing child Deworming every 6 months. Food Hygiene

26. At family level: Keeping food and water clean Washing hands before eating & after defecation. Fly control