CASE: ACUTE DIARRHOEA
DEMOGRAPHIC INFORMATION
• Name -
• Age -
• Sex –
• Address -
• Religion -
• Informant –
• Age -
• Education -
• Consanguinity -
• Date of admission -
• Date of examination -
§ How to explain the demographic information ~
Master/ miss .................., a ...... years old Hindu/Muslim/Christian/others, male/female
residing at .................... (address as name of village/town) in ................... (district name) was
admitted in Burdwan Medical College & Hospital on ................. (date of admission)
& ..................examined today.
Informant is ....................... (name), ....... years old, he/she is.................................
(relationship with the baby) of the baby/boy/girl and seems to be reliable.
CHIEF COMPLAINTS ~ Informer is complaining of (chronological order)
1. Vomiting
2. Pain in abdomen
3. Abdominal distension
4. Black tarry stool/bleeding per rectum
5. Loose stool/malformed stool
6. Constipation
7. Yellowish Discolouration of the eyes, skin
8. Decreased urine output
9. Painful mouth ulcers
10. Generalised swelling of the body
11. Decreased appetite
12. Fever
HISTORY OF PRESENT ILLNESS (Elaborate the Complaints with these points:
character+onset + nature + progressive or not + Duration + aggravating + reliving factor + any
special characters must be include + associated with any thing)
• According to the informer the baby/boy/girl apparently well .... days/months/yrs back.
• Then s/he developed -
1. Vomiting - onset, duration, progression, associated with nausea/not, number of
episodes, content, aggravating & relieving factors, blood stained, foul smelling,
feeling of increased thirst or loss of weight, associated with fever/ not, decreased
activity, associated with cough/ not, relation with food intake, bilious or non bilious)
, 2. Pain in abdomen - Onset, Duration, Progression, Site of pain, Type (colicky/ dull
aching), Radiation (radiate to the back/ abdomen/ hypogastrium/ localised),
Aggravating & Relieving factors, Associated symptoms
3. Abdominal distension - Onset, Duration, Progression, Aggravating & Reliving
factors.
4. Black tarry stool/bleeding per rectum - Onset, Duration, Progression,
Aggravating and Relieving factors, associated with mucus/not, colour & consistency
(black tarry/ dark red colour blood mixed with loose stool/ bright red blood
separating from stool/ bright red blood in small amount mixed with stool)
5. Loose stool/malformed stool - Onset, Duration, Progression, Colour, Blood
tinged/ not, Foul smelling/ not, Nature of the stools, Number of episodes in a day,
Apathy/Decreased activity, Type of Food taken recently, Time interval between food
intake and onset of Diarrhoea, How is the child in symptom free period, Associated
pain abdomen, Sensation of Incomplete evacuation of bowel, Association with
Fatigue or thirst or sunken eyeballs, Aggravating and relieving factors
[• Mother also complains of passage of loose stools by The baby since 4 days which
was sudden In onset, watery in consistency, Non foul smelling, initially 5-7 episode
per day later increased to 8-10 episode per day , yellowish in colour, non blood
tinged,scanty in amount no passage of worms in stool • Mother gives history
excessive thirst in baby and sunken eyeball which relieved after coming to hospital]
6. Constipation - Onset, Duration, Passage of flatus, Frequency of stools, Altered
consistency of the stools, Difficulty in passing the stools, Pain during defecation
7. Yellowish Discolouration of the eyes, skin - Onset, Duration, Progression,
Colour of sclera or urine or stool, Any aggravating factor & Reliving factors, Past
history or recurrence, Itching, GI Bleeding or bleeding elsewhere, Fever, Pain
abdomen, Apetite, History of blood transfusion
8. Decreased urine output - Onset, Duration, Progression, Associated swelling of
the limbs, Generalised swelling of the body, Headache, Body pain, Fatigue
9. Generalised swelling of the body - Onset, Duration, Progression, Started at,
Associated symptoms like, Decreased urine output, Yellowish Discolouration of skin
and eyes, Fever, Facial puffiness(early morning), Generalised swelling, H/o allergy,
Urticaria, Drug intake
10. Fever - Duration, Progression, Grade, Diurnal variation, Aggravating & Relieving
factor, Associated symptoms like irritability,unconsolable crying, chills ,headache,
nausea and vomiting, pain abdomen, burning micturition, yellowish discolouration
[Child was apparently alright 5 days back the the child developed fever, continuous
type, Moderate degree, not associated with rigors or any rashes, No diurnal variation
and relived on medication]
Chief complaints in case of
ACUTE DIARRHOEA- Loose stools, Pain abdomen, Fever
ACUTE HEPATITIS - Abdominal Pain (RUQ), Jaundice, Vomit
WILSON’S DISEASE - Pain abdomen (RUQ), Jaundice
DEMOGRAPHIC INFORMATION
• Name -
• Age -
• Sex –
• Address -
• Religion -
• Informant –
• Age -
• Education -
• Consanguinity -
• Date of admission -
• Date of examination -
§ How to explain the demographic information ~
Master/ miss .................., a ...... years old Hindu/Muslim/Christian/others, male/female
residing at .................... (address as name of village/town) in ................... (district name) was
admitted in Burdwan Medical College & Hospital on ................. (date of admission)
& ..................examined today.
Informant is ....................... (name), ....... years old, he/she is.................................
(relationship with the baby) of the baby/boy/girl and seems to be reliable.
CHIEF COMPLAINTS ~ Informer is complaining of (chronological order)
1. Vomiting
2. Pain in abdomen
3. Abdominal distension
4. Black tarry stool/bleeding per rectum
5. Loose stool/malformed stool
6. Constipation
7. Yellowish Discolouration of the eyes, skin
8. Decreased urine output
9. Painful mouth ulcers
10. Generalised swelling of the body
11. Decreased appetite
12. Fever
HISTORY OF PRESENT ILLNESS (Elaborate the Complaints with these points:
character+onset + nature + progressive or not + Duration + aggravating + reliving factor + any
special characters must be include + associated with any thing)
• According to the informer the baby/boy/girl apparently well .... days/months/yrs back.
• Then s/he developed -
1. Vomiting - onset, duration, progression, associated with nausea/not, number of
episodes, content, aggravating & relieving factors, blood stained, foul smelling,
feeling of increased thirst or loss of weight, associated with fever/ not, decreased
activity, associated with cough/ not, relation with food intake, bilious or non bilious)
, 2. Pain in abdomen - Onset, Duration, Progression, Site of pain, Type (colicky/ dull
aching), Radiation (radiate to the back/ abdomen/ hypogastrium/ localised),
Aggravating & Relieving factors, Associated symptoms
3. Abdominal distension - Onset, Duration, Progression, Aggravating & Reliving
factors.
4. Black tarry stool/bleeding per rectum - Onset, Duration, Progression,
Aggravating and Relieving factors, associated with mucus/not, colour & consistency
(black tarry/ dark red colour blood mixed with loose stool/ bright red blood
separating from stool/ bright red blood in small amount mixed with stool)
5. Loose stool/malformed stool - Onset, Duration, Progression, Colour, Blood
tinged/ not, Foul smelling/ not, Nature of the stools, Number of episodes in a day,
Apathy/Decreased activity, Type of Food taken recently, Time interval between food
intake and onset of Diarrhoea, How is the child in symptom free period, Associated
pain abdomen, Sensation of Incomplete evacuation of bowel, Association with
Fatigue or thirst or sunken eyeballs, Aggravating and relieving factors
[• Mother also complains of passage of loose stools by The baby since 4 days which
was sudden In onset, watery in consistency, Non foul smelling, initially 5-7 episode
per day later increased to 8-10 episode per day , yellowish in colour, non blood
tinged,scanty in amount no passage of worms in stool • Mother gives history
excessive thirst in baby and sunken eyeball which relieved after coming to hospital]
6. Constipation - Onset, Duration, Passage of flatus, Frequency of stools, Altered
consistency of the stools, Difficulty in passing the stools, Pain during defecation
7. Yellowish Discolouration of the eyes, skin - Onset, Duration, Progression,
Colour of sclera or urine or stool, Any aggravating factor & Reliving factors, Past
history or recurrence, Itching, GI Bleeding or bleeding elsewhere, Fever, Pain
abdomen, Apetite, History of blood transfusion
8. Decreased urine output - Onset, Duration, Progression, Associated swelling of
the limbs, Generalised swelling of the body, Headache, Body pain, Fatigue
9. Generalised swelling of the body - Onset, Duration, Progression, Started at,
Associated symptoms like, Decreased urine output, Yellowish Discolouration of skin
and eyes, Fever, Facial puffiness(early morning), Generalised swelling, H/o allergy,
Urticaria, Drug intake
10. Fever - Duration, Progression, Grade, Diurnal variation, Aggravating & Relieving
factor, Associated symptoms like irritability,unconsolable crying, chills ,headache,
nausea and vomiting, pain abdomen, burning micturition, yellowish discolouration
[Child was apparently alright 5 days back the the child developed fever, continuous
type, Moderate degree, not associated with rigors or any rashes, No diurnal variation
and relived on medication]
Chief complaints in case of
ACUTE DIARRHOEA- Loose stools, Pain abdomen, Fever
ACUTE HEPATITIS - Abdominal Pain (RUQ), Jaundice, Vomit
WILSON’S DISEASE - Pain abdomen (RUQ), Jaundice
