This document presents the case study of a 14-month-old boy named Zubayer who was admitted to the hospital complaining of loose watery stool and vomiting for the past 5 days. On examination, the boy appeared ill and dehydrated. Laboratory tests revealed anemia and normal electrolyte levels. The provisional diagnosis was acute gastroenteritis with some dehydration and moderate malnutrition. The boy was treated with oral rehydration and nutritional supplements. The family was counseled on maintaining proper hygiene and nutrition.

1. Welcome
Dr.SAQIB RAMZAN
Intern Doctor
Department of Paediatrics & Neonatology
Tairunnessa Memorial Medical College &
Hospital

2. Case Presentation

3. Particulars of the patient
• Name: Zubayer
• Age: 14 Months
• Sex: Male
• Religion: Islam
• Address:Board Bazar
• Date of admission:28/02/23 at 11:21 PM
• Date of examination:1/02/23 at 9:00 AM
• Informant: Mother

4. Chief Complaints
• Passage of loose watery stool several
times for 5 days.
• Vomiting for 8-10 times for same duration.

5. History of present illness
• According to the statement of patient’s
mother, her baby was well 5 days ago then
He developed passage of loose stool
which was watery in nature, yellowish in
color and profuse in amount. There was no
presence of blood or mucous in stool. He
also gives history of vomiting for 8-10
times for same duration which was non-
bilious and

6. Continue…
• non-projectile in nature and food particles
were present. With all these complaints he
admitted in this hospital for better
management.

7. • History of Past Illness: He was suffering
from diarrhoea 4 months ago.
• Drug History : History of taking Syrup
Azithromycin, Syrup Paracetamol.
• Family Histroy:He is the 1st child. Her family
consists of 3 members. They are all
reasonably well.
• Allergic History: He has no such allergic
history.

8. • Socio-economic History: He belongs to a
middle class family. Drinks tap water.
Economic condition is good.
• Immunization History: His immunization
is going as per EPI schedule.
• Travel History: There is no such history of
recent travels to hilly area or any endemic
area.

9. • Birth History: He is born by normal
vaginal delivery at term and his birth
weight was less than 2.5 kg. Antenatal and
postnatal period was uneventful.
• Feeding History: Breast feeding was
started from 4 hours of age and was on
exclusively breastfeeding until 4 months of
age and then formula milk was started.
Complimentary feeding has not started yet.

10. General Examination
• Appearance: Ill-looking, restless
• Body built: Poor
• Co-operation: Co-operative
• Decubitus: On choice
• Nutritional Status: Poor
• Anemia: Absent
• Jaundice: Absent

11. Continue…
• Clubbing: Absent
• Koilonychia: Absent
• Leukonychia: Absent
• Cyanosis: Absent
• Dehydration: Present
• Edema: Absent
• Tongue: Dry coated

12. Continue…
• Pigmentation: Absent
• Lymph node: Not palpable
• Bony tenderness: Absent
• Thyroid gland: Not enlarged
• Body hair distribution: Normal

13. Vitals
• Heart Rate: 120 beats per minute
• Respiratory Rate: 40 breaths per minute
• Temperature: 98.60F

14. Anthropometry
• Weight: 5.5 kg
• Length: 63 cm
• Weight for Length: -1.7 SD
• Length for Age: -2.7 SD

15. Systemic Examination
• GIT Examination:
• Inspection: Abdomen is distended in
shape, no scar mark, no visible pulsation.
• Palpation: Abdomen is soft and non-tender.
No organomegaly, no fluid thrill.
• Percussion: Tympanic, no shifting dullness.
• Auscultation: Bowel sound present.

16. Respiratory System
Examination:
• Inspection: R/R; 40 breaths per minute.
Chest indrawing: Absent
• Palpation: Trachea centrally placed.
• Percussion: Resonant
• Auscultation: Vesicular breath sound.

17. Cardiovascular System
Examination
• Inspection: No scar mark. No visible
pulsation.
• Palpation: Apex beat is present in left 4th
intercostal space medial to the mid
clavicular line.
• Auscultation: 1st and 2nd heart sound
present in all four areas, no added sound
present.

18. Nervous System Examination
• No abnormality is detected.

19. Salient Features
• My patient, Zubayer 14 months old boy, 1st
child of non-consangunious parents hailing
from Board bazar came with complaints of
loose watery stool for several times with
vomiting for 8-10 times for same duration.
Stool was profuse in amount and was not
mixed with blood and mucous. Vomit was
non-bilious

20. • and non-projectile in nature, mixed with
food particles.
On general examination patient was ill
looking, restless. Patient was thirsty with
dry coated tongue.
Heart rate was 120 beats per minute,
respiratory rate was 40 breaths per minute
and temperature was 98.60F.

21. Continue…
• Anemia, jaundice, cyanosis, clubbing,
koilonychia, leukonychia, edema, bony
tenderness, skin pigmentation were
absent. Thyroid gland and lymph nodes
were not enlarged.
On systemic examination of
Gastrointestinal system abdomen was
distended on inspection. Tenderness was
absent on palpation.

22. • On percussion tympanic note was present.
No shifting dullness. Bowel sound was
present on auscultation. Other systems
revealed no abnormality.

23. Provisional Diagnosis
• Acute Gastroenteritis with some dehydration
with moderate acute malnutrition.

24. Differential Diagnosis
• Dysentry

25. Investigations
• CBC with ESR
Hb%: 10.60 gm/dl
Total RBC count: 5.25x106/mm3
Total WBC count: 7500Cumm
Neutrophil: 55%
Lymphocyte: 38%

26. Continue..
• Serum Electrolytes
Na+: 142.44 mmol/L
K+: 4.40 mmol/L
Cl+: 106.24 mmol/L

27. Confirmatory Diagnosis
• Acute Gastroenteritis with some dehydration
with moderate acute malnutrition.

28. Treatment
 Rehydration therapy ORS 75 ml/kg with in 4
hours.
 Tab. Folinic acid.
 Diet: semi-solid such as khicuri mixed with green
banana & chicken.

29. Advice
• At individual level:
1. Advice to increase dietary intake to meet
the demand of the growing child.
2. Deworming every six months.
3. Food hygiene.

30. Continue..
• Family Level:
1. Keep food and water clean.
2. Washing hands before eating and after
defecation.
3. Fly Control.

31. Thank You.