2. History of personal data
• Name: Hibak Abdi Hassan
• Age: 2 years and 8 months
• Sex: female
• Residence: Hodan
• Date of admission: 19/12/2019
• Date of examination : 20/12/2019
• Informant: mother
3. History of chief complain
• diarrhea for 1 day
• Vomiting for 1 day
4. History of presenting illness
• Hibak was well until two days before , when she
developed diarrhea for 1 day , acutely onset ,
large amount , more than 10 times a day , rice
watery-like and watery in consistency , bad odor ,
and not contain mucus nor blood, associated
with abdominal cramping.
• Vomiting for 1 day, small amount, 10 times a day,
non projectile, no billous, no aggravating and
relieving factors, and associated with nausea.
6. PAST MEDICAL HISTORY
• She has previous similar condition 2 years ago
and has been admitted at CUBEYD HOSPITAL for
GIARDIASIS .
• No chronic and congenital heart diseases.
• No blood transfusion .
• No previous operations .
• No history of imaging .
• No history of traveling .
• No known drug allergy .
8. Birth history
A: Ante-natal Care
• The mother was 37 years old at the birth of
Hibak .
• She hasn’t visited MCH routinely during her
pregnancy but completed her TT/td
vaccination previous pregnancies .
• She visited MCH ( hanano) once for sudden
bleeding at two months of the pregnancy .
9. • No supplements taken during pregnancy .
• No bad habits ; smoking or alcohol .
• INTERPETATION : POOR ANTE-NATAL CARE
10. B- natal history
• She was born at hospital for full term ; 40 weeks
with spontaneous vaginal delivery , cephalic
presentation at Medina hospital .
• The membrane rupture was 5 mins before the
labor , duration of the labor was around 1 hour
and placental delivery took around 10 mins .
• The apgar score is unknown.
• No complication during labor
• INTERPRETATION : GOOD NATAL HISTORY
11. C – post-natal history
• Baby cried immediately , pink in color , no
cyanosis , no jaundice , no pallor , no
convulsion and went home with her mother
few hours after delivery.
• Started breastfeeding after 30 minutes as the
mother said .
• Meconium was passed in the first 24 hours .
INTERPRETATION : GOOD POST NATAL HISTORY
12. Feeding history
• Started breast milk and water 30 minutes after birth ,
frequency of breastfeeding was 4 times a day , and
each one for 30 minutes.
• Started weaning after 6 months ; potato , liver ,
vegetables , fruits , pasta and water, 2 times a day and
continuation of breast feeding.
• INTERPRETATION: NO EXCLUSIVE BREASTFEEDING .
13. Immunization history
• She took BCG and OPV 0 at left upper arm and mouth
respectively at 5 days after birth.
• When she was six weeks of age she got OPV 1 and
PENTA 1 orally and anterolateral mid thigh .
• At 10 weeks of age she took OPV 2 and PENTA 2 orally
and anterolateral mid thigh respectively .
• At 14 weeks of age , she took OPV 3 and PENTA 3
orally and anterolateral mid thigh
• At 9 months , she took measles vaccine at right upper
arm.
• She has completed the vaccine at Hanano hospital.
• Interpretation: complete vaccination
15. Developmental history
• Gross motor: she is able to walk a line and walk a
backward, she can catch a ball, and jump with two feet.
• Fine motor: she can dress her self with a little
assistance , she can turn pages in a book, and can drink
with out assistance.
• Speech , language , and hearing: she understands and
commands, she can say words .
• Social , emotional and behavioral: she smiles , feeds
her self solid foods , drinks from a cup , helps with
tasks like dressing.
• Interpretation: good developmental history
16. Social history
• Home: maternal attitudes is good , father and
mother are separated due to death of her father
for gun shot , so her father is absent.
• Housing: they live in their own house that consist
of two rooms , one kitchen , and one tube , they
do not use net , and no animals in the house.
• The mother is a house wife and the father has
passed away.
• There is no bad habit in the family.
17. Family history
• The age of the mother is 40 years and her
health is good.
• The family income is poor , family size is small
and no bad habit.
• She has eight siblings ( one sister , five
brothers , and two siblings are died)
• No consanguinity.
18. Physical examination
• General condition : patient looks ill , lethargic,
sunken eyes , dry mucus membranes , un able to
drink and feeding , have NG-tube for feeding.
• Interpretation: severe dehydration.
vital signs
On admission on my examination
Temperature: 36.3 c temperature: 36.8 c
Pulse rate: pulse rate: 130 b/m
Respiratory rate: 28 b/m respiratory rate: 25 b/m
Interpretation : Normal vital signs
19. • Skin: skin turgor goes back quickly .
• HEENT : Sunken eyes , other are unremarkable
• Respiratory system
A- Inspection= symmetric of breathing , didn’t
use of accessory muscles for breathing , RR
was 25breath/m
B- Auscultation = equal breath sounds , no
rhonchi , no wheezes , no upper airway noises.
20. • Cardiovascular system
• Extremities: warm as normal .
• Pulse: strong or normal volume , and PR was
130b/m
• No heaves no thrills .
• S1 and s2 are normal and no extra heart
sounds .
21. Abdomen
• Inspection: no scaphoid/ no distended , no
umbilical hernias.
• Palpation: skin turgor backs rapidly , no
hepatosplenomegally, no tenderness , no
guarding and no masses.
• Percussion: no ascites and no fluid thrill
• Auscultation: bowel sounds are present.
22. Mss ,spine , neurological
• Are all un remarkable
23. Anthropometric measurement
• Weight: 13.9 kg
• Height: 100 cm
• Z-score: <-1
• HC: 52cm
• Muac: 13 cm
• WFA: 50th percentile
• HFA: 95th percentile
• Interpretation: Normal according to age .
24. Case summery
• Hibak Abdi Hassan is a 2 years and 8 months old female
whose weight 13.9 kg and a height of 100 cm was
admitted to banadir hospital on 19/12/2019,
complaining of diarrhea for 1 day, acutely onset , large
amount , more than 10 times a day , rice watery ,
watery in consistency , bad odor associated with
abdominal cramping.
• Vomiting for 1 day small amount more than 10 times,
non bilous , no aggravating and relieving factors.
• Her examination : looks ill, lethargic , sunken eyes ,
dry mouth , un able to drink , NG-tube.
• Vital signs: RR: 25 b/m temp: 36.2 c PR: 130 b/m
28. Management
• Ringer lactate 100ml/kg:
– Phase 1: 417ml for the first one hour
– Phase 2: 973ml for the second five hours
• ORS solution: 1,112ml for four to six hours
• Zink tab 20 mg 1x1
• albendazole tab 400 mg 1x1
• Antibiotic: erythromycin tab 250 mg 1x2
29. Progressive notes
• 21/12/2019 : story: patient was complaining
diarrhea 3 times , large amount yellowish in
color , bad odor and vomiting for 2 times
which is small amount.
• Objective: conscious , alert , sunken eyes ,
dry mouth , normal urine output , v/s: T=
36.2c RR= 26 breath/m
• Assessment: some dehydration
• Plan: continue treatment.
30. Progressive notes
• 22/12/2019 Story: her complain was diarrhea
one time , small loose stools no vomiting
• Objective: conscious , alert , looks ill , no
sunken eyes, no dry mouth , normal pulse
volume , skin pinch goes back rapidly, chest
clear , abdomen soft.
• Assessment: no signs of dehydration
• plan: normal discharge
31. Discharge recommendations
• I gave ORS packets enough for 2 days , at
discharge a long with instructions and how to
prepare ORS solution and advice on when to
seek care.
• I taught the mother on safe hygienic practices
before discharge ( hand washing , safe boiled
water )
• I recommended to mother, give her baby Zinc,
and give extra fluid(water).
• Return, if there is any danger sign.
