General case

history

• Name: Shreya• Age : 2.5yrs , sex: female• From: Shimoga• Informant: mother, Reliability : good• Came to RAPCC 15days back with • Chief complaints: • enlarged head , loss of vision , seizure since

2yrs4months

History of presenting illness• Child was apparently normal 2yrs4months back when she

developed fever for which the mother gave paracetamol tablet. Fever decreased but spiked up again on the 8th day with one episode of seizure. There was no frothing of saliva or biting of tongue. The hands and legs became stiff which normalized within 2-3 minutes. Baby was admitted in the ICU at a local hospital ,treated and was discharged on medications for seizure, a tablet and syrup.

• Every time the mother gives the child head bath, she develops seizure.

• History of loss of vision since 2yrs 4 months.• The child does not recognize the mother and no social smile

present.

• No other episodes of fever. No history of vomiting.• No history of difficulty in feeding .• When the child did not improve, mother took her to

manipal hospital 2months back where scans were done and mother was told an operation would be required. She was referred to RAPCC.

• No history of difficulty in chewing.• No history of lateral gaze palsy.• No history of hearing deficit, drooling of saliva, nasal

regurgitation .• History of difficulty in wearing napkins.

Birth history

• Antenatal history: primigravidaIst trmester:Concieved spontaneously.No history of fever with rash, burning

micturition.No history of exposure to radiation or intake of

drugs. Ultrasound scan not done.

2nd trimester: quickening felt at 6th month.No history of fever with rash.No history of GDM, PIH.One USG scan done-nnormal3rd trimester:No history of GDM, PIH.USG scan done-normal.

• Full term delivery.• Elective caesarian section due to decrease in

fetal movements.• Baby cried immediately after birth.• Birth weight:2.75 kg• Meconium and urine passed within 24hrs.• Breast feeding initiated after 4hrs of delivery.• No postoperative complications.

Developmental history

• Gross motor- head control not achieved• baby cannot sit with support• Fine motor- grasp reflex present.• Language and communication: bysyllables

(amma) only word spoken.• Social: no social smile• does not recognise the mother• Inference: global deveopmental delay

Immunization history

• Immunized for age• Last vaccine taken: 1.5 yrs- DPT booster and

OPV.• Dietary history:• Exclusive breast feeding till the age of

5months.• Weaning : 5th month, cerelac given.• Presently eats from the family pot.

calories protiens

8am 5buiscuits+ I cup milk(200ml)

100+ 130= 230 0+7=7

10am ½ dosa 60 1.5

1pm 1 cup rice+I cup curry

175+50=225 4+ 2=6

3pm 1 fruit 50 0.5

5pm 5buicuits +1cup milk

100+130=230 0+7=7

7pm I cup rice+ 1 cup curry

175+50=225 4+2=6

9pm 1cup milk 130 7

total 1150 35

required 1150 19.5

Inference: no deficit

Family history

• Child born out of consanguinous marriage

Socio economic history

• 5 members in the family• 3rooms, no over crowding• income rs 4000/month• Belongs to lower middle class family according

to Modified Kuppuswamy scale.