IMPORTANCE OF CLINICAL OBSERVATION

A 5 year old female child from Calcutta got admitted in A.C.S.Medical College & Hospital, Velappanchavadi, Chennai-77 on 4th Feb’14.

Main Complaints:
Abdominal pain on and off 2 years.
Constipation on and off 2 years.

?Abdomnal pain more in umblical area, subacute, spasmodic, not associated with vomiting or fever. Everytime the pain subsided with symptomatic treatment.

?Constipation – Hard, formed faecal matter
Being passed once in 2 to 3 days.

For the above complaints child was admitted a year ago in a corporate hospital in Calcutta. She was investigated extensively and her father was informed that nothing was wrong with the child.
Child had to discontinue her school (even though she was above average in studies) due to frequent absenteeism (because of abdominal pain).

She was admitted this time to A.C.S.Medical College to investigate her abdominal pain and constipation.

Blood, Urine, Ultrasonagram of abdomen, X-Ray of Chest, abdomen, C.T.Scan of abdomen, M.R.I. of brain with contrast study yielded no abnormality.

During her stay in hospital lasting 3 to 4 days certain strange behaviours were noted by the duty doctors and staff nurses. They were:-

a. Hyperactivity
b. Voracious Appetite
c. Craving for food all the time.
d. Sleeplessness.

a. Hyperactivity:
The child was never found sitting in one place more than 10 to 15 minutes. Running, jumping, pushing (or) pulling articles were all noticed. She slept only for 5 to 6 hours. She was not scared of anyone (father, strangers, staff nurses or even group of doctors). She was conscious, well oriented with time and space.

b. Voracious Appetite:
The child’s appetite and eating habits were strange but her father gave no importance to her behaviour. As soon as she woke up in the morning she would demand something to eat or drink. She was consuming about 8 to 10 chocolates, 200mls milk and a packet of biscuits as soon as she woke up. She would go to the canteen herself and demand whatever was kept for sale. She used to take four full meals per day, 8 to 10 plantains, biscuits, fruit juices and chocolates were all added to her diet.

Her consumption of food on average was:

Total protein 65 gms / day as against 20 gms of normal requirement for her age and weight.
Total calories were 1300 k.calories / day as against 800 k.calories / day.
In contrast her weight / age was showing grade I under nutrition.

By observing her habits and behaviour, we decided to evaluate her thyroid function.

Thyroid scan was normal.
T3 – 800 nanogram / dl
T4 – 14.58 microgram / dl
TSH – 0.420 I.U / ml
Immunoassay Free T3 – 7.7 ng / dl
Free T4 – 1.33 ng / dl
TSH – 0.07 I.U / ml
Thyroid peroxidase antibody
Less than 3.0 I.U / ml
Thyroglobuin antibody
0.29 I.U / ml
BMI
BMR were almost normal.

Since we thought she may be suffering from primary Hyperthyroidism, Tab.Propanolol 5 mg BD was prescribed.
Within a week of treatment we noticed a remarkable change in her hyperactivity, appetite and behaviour.

Hyperactivity:- The child started to sit quietly playing with video games. Her sleeping time was increased. She became more friendly with all on the ward.

Appetite:- She was not demanding food. She was satisfied with whatever was offered however small in quantity. Her intake had reduced enormously. Total protein intake reduced from 65 gms / day to 20 gms / day. Total calories consumed from 1300 k.calories / day to 850 k.calories / day. Her abdominal pain disappeared.

Since the family came from Calcutta they returned home with the promise to continue her treatment in Calcutta.

She will be reviewed in our hospital in 3 months.

Summary:

?The child presented with an odd behaviour with a number of diverse clinical findings.

? Had a voracious appetite consuming more than three times the normal required quantity of food but with chronic constipation with under nutrition.

?Was hyperactive with normal mentation.

?The BMI and BMR were almost normal.

?Unexplained, subacute abdominal pain which subsided with Tab.PROPANOLOL within few days of prescribing was a pleasant surprise.
The hyperactivity and voracious appetite also reduced to almost normal level.

The child’s successful medical management was mainly due to vital clues provided by duty resident doctors and ward staff nurses who were observing her behaviour while she was on the ward.

During our training our teachers taught us the importance of history taking, checking the occupation, place of living, personal habits and observing the behaviour of patients. With modern trends using sophisticated equipment and investigative procedures the importance of individual observation is fading away.