7 yr old male child with Stomach pain,Bloating and Mouth ulcers

July 08, 2022

7 yr old male child with Stomach pain,Bloating and Mouth ulcers

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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.

7 yr old male child was admitted with chief complaints of Stomach pain , bloating and Mouth ulcers

HOPI:-

Patient was apparently asymptomatic 18 months ago, then one night after eating at a family party and returning home He started complaining of pain in the Stomach around epigastrium and umbilical region and bloating in half an hour.

These complaints persisted for another 10 days.So he went to a doctor(1st) who prescribed medicine for 1 month and( doctor advised to stop giving egg, milk, ghee to the child) the symptoms were relieved.Then again he started taking Milk,Egg,Ghee.(stomach pain is present before eating and increases after taking meal ,abdomen becomes distended but there was slight decrease in stomach pain after passing stools)

After 1 month he developed high fever (102 °F ) with mouth ulcers in the oral cavity for which he went to child specialist and was referred to dental doctor who prescribed medication for 7days.But he was not fully recovered and was having recurring mouth ulcers since then.Occasionally he complained about chest pain.

After 1yr he developed same symptoms again

(Stomach pain,bloating) so he went to the same doctor (1st) who prescribed medication for 1month and the symptoms were relieved.

4 months back again he developed same symptoms and was treated by another doctor(2nd)

who prescribed medication for 1month and the symptoms were relieved.

In the same month(march) he developed night fever for 3-4days

Next month(april) he developed cold ,sneezing and chest pain for 15-16 days which was treated and he recovered.

20 days back he again developed same symptoms and treated by another doctor(3rd) and was given medication. Upon giving medication for 2days his mother felt that his symptoms are aggravating so she stopped the medication and consulted with another doctor(4th) who prescribed medication for 15 days and then to watch for any improvement.Upon giving medication for 10 days his mother felt there was no improvement .So he was shifted to our hospital yesterday evening.

Daily routine:

He wakes up at 8am and the brushes and take breakfast (Banana+Milk+Roti) around 8:30 am then from 9-11 he studies/watch television.Again around 11am he takes his lunch(rice+dal+fish fry).After lunch he takes his bath(12pm).After that he play with his toys and spends time around his little sister.

Again at 3pm he takes his food(rice+dal+fish curry) and goes to sleep till 5pm.Around 5:30 pm he takes Milk +banana+rice product(Mudi).

Then he watches TV and study for some time.

At 9:30 pm he takes his dinner(rice+dal+potato fry/boiled Egg/fish) and spends time with his family.

He goes to sleep around 12-1 am.

Mother also Complained that he wasn't sleeping until late at night.

Past history:

Not a k/c/o Asthma,HTN, DM, TB, epilepsy.

Personal history:

Diet:Mixed

Appetite:Decreased

Sleep:Normal

Bowel and bladder movements:Regular