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Child Gastroenteritis Case Study

A 2-year-old male child presented with vomiting and diarrhea for the past two days without fever. On examination, the child had dry tongue, sunken eyes, and prolonged capillary refill time, indicating mild to moderate dehydration. Based on the symptoms and examination, the child was assessed to have acute gastroenteritis likely caused by a viral infection such as rotavirus. The management plan was to provide fluid resuscitation with oral rehydration solution and nutritional support, as the condition should resolve within 1-2 weeks.

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27 views11 pages

Child Gastroenteritis Case Study

A 2-year-old male child presented with vomiting and diarrhea for the past two days without fever. On examination, the child had dry tongue, sunken eyes, and prolonged capillary refill time, indicating mild to moderate dehydration. Based on the symptoms and examination, the child was assessed to have acute gastroenteritis likely caused by a viral infection such as rotavirus. The management plan was to provide fluid resuscitation with oral rehydration solution and nutritional support, as the condition should resolve within 1-2 weeks.

Uploaded by

moustafaessam58
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Clinical Case

Child Health
Module
Mostafa Essam Rabie Y4 202000010
Case
1
Social history &
Complaint
• Patient Name: Mohmmed Islam Ahmed
• Age: 2 years
• Gender: Male
• Has an older sibling
• No consanguinity

■ "The child is not eating or drinking


well and has been experiencing
vomiting and diarrhea for the past
two days with no fever.”
Analysis of the complaint
v Started 2 days ago
v Sudden onset
v Progressive coarse
Vomiting v Related to meals
v 3 – 4 times per day
v Color of the food
v No blood
v Not projectile vomiting

v Started 2 days ago


v Sudden onset
Diarrhea v Progressive coarse then regressed
v Was 5 times then regressed to 2 times
v Was brown then yellowish
v Watery diarrhea
v No blood
v No mucus
v Sometimes related to meals sometimes not
Past Medical v Covid-19 1 month ago and resolved
v No drug history

v Prenatal: no complications
Perinatal v Intranatal: Hospitalized C section because of late labour
v Postnatal: Normal full-term baby (3kgs)

v Up to date
Vaccinations ü At birth ( BCG-OPV-HEP B)
ü 2 months (IPV-OPV-PENTA)
ü 4 6 9 months (IPV-OPV-PENTA)
ü 12 months (OPV-MMR)
ü 18 months(OPV-MMR-DPT)
Developmental v Normal developmental milestones

v Breastfed for month then formula because of fever


v Both sides
Nutritional v 4 times a day
v Sleeps after feeding
v On demand
v 30cm then 100cm
v Took vit supplements and folic acid
v Weaned at 6 months started with yogurt then other stuff

Travel
v No travel history
Drug history v Not on regular medications

Family and social v No family history


v No consanguinity
history v Passive smoker
On Physical examination
Decreased skin
Dry tongue Sukun eyes
turgor

Prolonged
capillary refill
Investigations
v Complete blood count (CBC)
v ABG
v Kidney functions
v Liver functions
Assessment and the
plan
q Based on the presenting symptoms,
physical examination findings, the patient
may be diagnosed with mild to moderate
dehydration secondary to acute
gastroenteritis caused by viral infection (
most common Rota virus )

q The initial management plan


includes:
Ø Fluid Resuscitation (ORS)
Ø Nutritional Support
Ø Resolves within 7-14 days
Thank You

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