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

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

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

5.  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.  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.  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.  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. MEAL Food Item Consumptio
n/day
Calories
(kcal)
Proteins
(gm)
Carbohydrat
es (gm)
Fats
(gm)
Iron
(mg)
Calciu
m (mg)
Breakfa
st
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
Afterno
on
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. 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. 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. 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

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