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Under 5- ARI

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Vijayapriya Palanisamy
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2 views

Under 5- ARI

Uploaded by

Vijayapriya Palanisamy
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
You are on page 1/ 7

PART-1: FAMILY/SOCIAL STUDY

Family Iden<fica<on details


Name of the child: ?

Age/ sex:2 1/2 /F

Address: Chromepet

Religion: ?

Name of the informant: mother

Reliability: Good

Family composition
S . Name A g e / Rela<on to Head M a r i t a l Literacy Occupa<o Income
No. Sex of family status n
1 Grandf M Head of the family married ? - -
ather
2 Grand F wife married ? - -
mother
3 husban M son married ? ? 20000
d
4 wife F daughter in law married ? ? ?
5 Elder M Grandson - UKG - -
brothe
r
6 Child F Grand daughter - - - -

Type of family: Three genera<on family

Socioeconomic history
Total family income: 20000

Per capita income: 20000/6 = 3333

Socioeconomic status of family: Middle class as per modified BG prasad classifica<on


(Rural/Urban area: Modified B G Prasad classifica<on; Urban area: Modified
Kuppuswamy’s classifica<on)

Environment and Sanitation


Type of house: Pucca

Roof: bricks

Flooring: Tiled

Walls: Burnt brick

No. of rooms: 2

Overcrowding: Yes

Separate kitchen: Yes

Fuel used: Coal or firewood/ Kerosene/ LPG

Smoke outlet: Present/Absent

Ven<la<on: Adequate/Inadequate

Cross-ven<la<on: Adequate/Inadequate

Ligh<ng: Adequate/Inadequate

Source of Drinking water:

Water for other purposes:

Distance of water source from house:

Frequency of supply:

Storage of water:

Is water boiled before drinking: Yes/ No

Toilet type: Separate/ shared/ public/ open air defeca<on

Type of latrine: Sanitary/Insanitary

Refuse disposal:

Sullage disposal:

Sewage disposal:
(How are the excreta of babies & young children disposed?):

Mosquito or Insect breeding in & around the house: Present/ Absent

Fly breeding in & around the house: Present/ Absent

Rodent nuisance: Present/ Absent

Cable & pet animals: Absent

PART II: CLINICAL CASE STUDY

CLINICAL HISTORY

Presenting complaints:
Fever for 4 days.

Cough and noisy breathing for 2 days.

H/o Present illness:


The child was apparently normal 4 days back ader which she developed fever for 4 days
which is acute in onset, grade(?), remibent in type and is not associated with chills and
rigors. She also developed cough and cold for 2 days which is gradual in onset, produc<ve
type and is associated with running nose. She also has h/o noisy breathing for the past 2
days.

No h/o sore throat, ear discharge, cyanosis.

Past history:
No similar complaints in the past.

No h/o nebulisa<on.

Treatment history:
No h/o drugs taken.

Personal history:
Normal appe<te and disturbed sleep.

Regular bowel and bladder habits.


Family history:
H/O exposure to grandfather who is a smoker and is on treatment for COPD.

No h/o asthma, cys<c fibrosis.

Dietary history:
Total calories consumed:1005 kcal/ day including 18 g of protein.

RDA:1060 kcal and 16.7 g protein.

Antenatal history:
Booked case.

All 3 scans done.

2 doses Td given.

IFA tablets taken.

No h/o fever with rash, GDM, PIH.

Birth history:
Place of delivery: tambaram GH

Mode of delivery: normal vaginal delivery

Birth weight: 2.9 kg

Baby cried immediately ader birth.

Passed meconium and urine within 48 hrs.

No H/O respiratory distress and jaundice in NICU.

Feeding History:
Breaskeeding started within half an hour.

Baby is exclusively breasked for 6 months.

Complementary feeding was started by the 4th month.

Any pre lacteal feeds.


Immunization History:
Immunisa<on done <ll date.

Last vaccine-?

Follow NIS/ other

Immunised in government or private hospital.

Whether any op<onal vaccines.

Any adverse reac<ons ader immunisa<on.

Developmental history:
Normal milestones achieved upto age.

PHYSICAL EXAMINATION

GENERAL EXAMINATION:
The child is irritable and crying.

Built and nourishment.

No PICCLE.

Vital signs:
Pulse rate:116/min

Respiratory rate: 42/min

Blood pressure:? mmHg measured in ______ limb in _______ posi<on

Temperature:Febrile(100 F)

ANTHROPOMETRY:
Weight: 9 kg

Height:88 cm

Mid arm circumference: 13 cm(in all children 1-5 years)

HEAD TO TOE EXAMINATION:


Hair- normal in colour and texture
Eyes, ears, nose, mouth, chest and limbs normal.

SYSTEMIC EXAMINATION
RS

Inspec<on:

Chest wall bilaterally symmetrical.

Trachea appears to be in midline.

Chest moves equally with respira<on.

No h/o fast breathing.

No h/o chest indrawing.

No visible scars or engorged veins.

Palpa<on:

Trachea in midline.

No tenderness over chest wall.

Chest moves equally on both sides with respira<on.

Use of accessory muscles noted.

Percussion:

Resonant sound heard on percussion.

Ausculta<on:

Expiratory wheeze/ stridor can be heard.

CVS: S1S2 heard and apical impulse felt on 5th ICS.

GIT: Umbilicus inverted and no visible scars or sinuses.

Probable diagnosis:

__ a 2 1/2 yr old female child coming from chromepet belonging to a middle class family
accompanied by her mother came with remibent fever for 4 days and produc<ve cough
for 2 days associated with running noise and noisy breathing. O/E the child was tachypnic,
use of accessory muscles was noted and expiratory wheeze/stridor could be heard.
Therefore my probable diagnosis is ARI:
LABORATORY INVESTIGATIONS:
CBC.

X-Ray chest.

Level of prevention failed:

Primary.

Advice:
Individual: Good and nutri<ous diet.

Regular immunisa<on.

Family: Maintain a clean indoor environment.

Prevent dust exposure.

Personal hygiene of family members to ensure that communicable diseases does


not spread to the child.

Community:

Immunisa<on of all children.

Prevent dust exposure.

Personal protec<on and hygiene.

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