PBL 3 session 2

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PBL 3 session 2 by Mind Map: PBL 3 session 2

1. Step 8

1.1. Diagnostic decision

1.2. Mechanism

1.3. Presentation

1.4. Supporting data

1.5. 10 minutes

1.6. next session

1.6.1. management of dehydration

1.6.2. grwoth

1.6.3. gastroentritis

2. Step 7

2.1. Inquiry plan and info gathering

2.1.1. History of presenting complaint 10 dirty nappies with green stool vomited all formulas not eating well hot to touch sleeping more 2 siblings got diarrhea this week tends to cry a lot and wake regularly at night tried different formulas her sister mentioned the wight loss

2.1.2. Previous medical / surgical history 2 episodes before of gastroentritis 4 7 breastfead for 2 weeks stool was soft mustard color once a day, then it became firm after shifting to formula immunization: 2 and 4 months changed to S26ar anti reflux at 3 months developed nappy rash, changed fomula from pharmacist went back to the anti reflux at 5 months changed formula again with apple juice

2.1.3. Drug history / allergy none

2.1.4. peri natal history at term 40 weeks vaginal 3.15 KG 49 cm 35 head circumference ABGAR score 8 and 9 pregnancy complicated with unreported bleeding missed number of appointments HBv immunized discharged on day 4

2.1.5. Family history NOT significant

2.1.6. Social / occupational history father husband busy long working hours including weekends brother and sister mother feels tiered and stressed 24 did high school ant talk on the phone offer advice grandmother lives away and gives visits 44 yo

2.1.7. development rolled over at 5 months can sit without support grasp objects

2.1.8. Systemic review

2.1.9. Physical examination vitals temp 38 pulse 130 BP 85/60 rr 40 central capillary refill less than 2 seconds chart lenght 25th percintile HC 25-50 percintile wight less than 3rd percintle inspection thin lying in mother's arm dry mouth and cool periphery skin folds visibile on inner thighs sitting supported palpation palpable liver rash on the hand scratch marks on hands and trunk ear normal

2.1.10. tests results urine RBC less than 10 no protein WBC 10^100 culture mixed growth hematology HB 90 microcitosis biochem K reduced urea increased Na increased creatining increased bicard reduced blood culture no growth stool detected rotavirus no bacterial pathogen

2.2. 50 minutes

3. Step 6

3.1. Review session 1

3.2. Report new knowledge

3.2.1. Failure to thrive evaluation causes malnutrition malabsorbtion

3.2.2. diarrhea and vomiting in infants infection other causes

3.3. 30 minutes