Malnutrition

Seen a patient who presented with history of body swelling for 1 month, that was of gradual onset
started from the legs, progressively increasing in severity to involve the face, the swelling was
bilateral, not associated with any history of itching, but with history of skin ulceration on affected
areas, the swelling was not related to positioning, with unknown aggravating or relieving factors.
Informant reported no history of bluish yellowish discoloration, no history of difficulty in breathing, or
excessive sweating during breastfeeding. No history of fever, vomiting or history of difficulty in
swallowing. Has no history of passing frothy urine, no history of reduced urine output, or body
itching.
On course of this illness, the patient has history of outpatient visits, where by she was treated for
Anemia, and was given hematenics with no improvement.

No history of admission, no history of blood transfusion, no known food or drug allergies,

PRENATAL HISTORY
The mother booked the first visit at antenatal clinic at 20 weeks of pregnancy and subsequently
visiting 5 clinics thereafter. She reported to have received, sulphadoxine pyrimethamine x2,
mebendazole and hematenics, received tetanus toxoid vaccine x2, PMTCT 2, VDRL non reactive.
She reported no history of fever, bleeding or hypertension during the pregnancy, no history of any
other complications during pregnancy,

NATAL HISTORY
The child was delivered at term by SVD 2.8kg,cried immediately after birth, the child breast within
the 1 hours of life.
POST NATAL HISTORY
She was discharged after 24 hours, cord drop within 7days. The mother reported no difficulty in
sucking, no bluish or yellowish discolouration of the skin, palms or soles

IMMUNIZATION HISTORY
The patient has received all the vaccinations according to the immunization and vaccination
development program according to age.
BCG scar seen.( information acquired from RCH card 1)

DEVELOPMENTAL HISTORY
can seat without support can stand without support, turns on to her name, can say mama, baba,
has stranger anxiety.
CONCLUSION NORMAL DEVELOPMENTAL MILESTONES

DIETARY HISTORY
The child was never breastfed because the mother was unable to produce milk. Used infant formula
milk, and started complimentary feeding at 4 months, where by she takes 4 meals per day, in the
morning and night porridge composed of maize only (dona ), also takes potatoes and bananas in the
noon and evening, also drinks diluted beverage juices, rarely takes fish, meat and vegetables.
CONCLUSION DIET POOR IN QUALITY AND QUANTUTY (No enoh protein, vitamins and
minerals)

Social hx and family Grandmother is the primary caretaker of the child, mother is an entrepreneur,
father is business man, the child has no health insurance card, has siblings who are doing fine, there
is no familial history of chronic illnesse
PLAN
PDX: 1 Severe acute malnutrition kwashiorkor type
2. Iron deficiency anaemia
3. Oral mucositis

Plan
1. To do FBP, electrolytes, PITC, Urine dipstick for proteins
2. Start IV Ampiclox 700mg TDS for 5 days
3. F75 88mls/3hourly for 24 hours
4. Oral cure gel topical BID for 7 days
5. Tabs folic acid 5mg OD for 14 days
6. Tabs Zinc 20mg OD for 14 days
7. Vitamin A 100,000IU for 2 days
8. Monitor weight after every 24 hou

ACUTE WATERY DIRHOEA

reveiwed the patient from EMD, self refferal the informant is her mother, the patient was apparently
well until yesterday presented loose stool for 1 days initially had 5 motions yesterday night and 3
on day of admission which was watery in nature, non foul smelling, no blood in stool which was ass
with abdominal pain and low grade fever , 1 episode of non projectile vomiting, of feeds she took,
that contained recent eaten material , convulsion, LOC,
also the patient presented with crying during urination for 1 day of gradual onset, no any hx of blood
in urine
ROS- no any positive findings

SICKLE CELL
received patient from RCH clinic, This is a know case of sickle cell who diagnosed 6 month ago, on
folic acid 5mg, brought due to a complain of fever for one day which was of gradual onset, on and
off, relieved by paracetamol associate with difficult in breathing not associated with cough,
wheezing, chest tightness. The grandmother reports no hx of convulsion, no LOC, no discomfort
during feeding no crying during urination no blood during urination, no ear discharged however the
patient has a painful swollen toe on the left foot that started after the fever. The mother reports the
patient to have similar episodes of fever and swollen on the right arm three weeks ago.

SAMPLE 2

received patient from RCH clinic, This is a know case of sickle cell who diagnosed since 5 month of
age, on folic acid 5mg, brought due to a complain of abdominal pain of one day which was of
gradual onset, on and off, relieved by paracetamol associated with joins pain of both upper and
lower limbs that started 1 day prior admission The mother reports no hx of convulsion, no LOC, no
discomfort during feeding, no crying during urination no blood during urination, no ear discharged
however the, no yellowish discoloration of eyes, change in bowel patter, no blood in stool.
MEASLES
Received the patient from EMD came with the chief complaint of Fever which was of low grade on
and off with no specific periodicity which releaved by paracetamol however no any history of
headache,convulsion or loss of consciousness reported.No history of increased frequency of
urination, painfull urination,blood in urine or any history of abdorminal pain reported.
2 days later, he started to experienced mouth laceration,redness of the
eye followed by perineal laceration and finally skin exfoliation however his sister reported no any
history of currently use of medication prior to the onset of the symptoms and no any known allergy of
food or drugs reported.
Furthuremore, the patient started to experienced history of cough for 3 days which was non
productive initially and currently is productive with no specific periodicity, it was associated with on
and off episode of non projectile vomiting which was non bilious,not blood stained which containing a
recently eaten food materials however no any history of difficult in breathing reported.
Moreover, he had not received a Measle and Rubella vaccine at 9 and 18 months of his age.

PLAN MEASLES

DX, Measles with pneumonia DDX Steven johnson syndrome

Moderate Anemia not in failure,Malaria,UTI

To do FBP,MRDT,Urinalysis
IV Benzalypeni
cillin 1MIU 6houly
IV Gentamycin 51mg od
T.Folic acid 5mg od
Vitamin A 200000IU at 1,2 and 14 days
Oracure BD
Hydrogen peroxide 3% mouth wash 8 hourly

PNEUMONIA

he patient presented with history of cough since 3 days ago which was of gradual in onset
progressive increasing as the time goes on, it was associated with difficult in breathing, lower chest
indrawing's, nasal congestion, and fever which was on and off and relieved by paracetamol,
however no any history of convulsion or any history of loss of consciousness reported. Prior
admission the mother reported to have attended Kambangwa H/C where she was referred to our
facility. Mother reported no hx of vomitting, passing of loose stool, painful urination, or blood in urine.
WARD ROUND

SYTEMIC
Alert, afebrile, not pale, not jaundiced, not cyanosed, no LL edema. VITALS: temp 38.1 PR, 126bpm
RR, 69bpm Spo2 98 on room air. S/E RS Symmetrical chest movement,symmetrical chest
expansion, Resonant note on percussion Vesicular breath sound. CVS Regular rhythmic pulse,
radial pulse synchronize with femoral pulse, No raised JVP, Apex beat at 4th left intercoastal space
MCL, s1 and s2 heard. CNS Alert to PPT, GCS 15, no sign of meningeal irritation, all 12 cranial
nerves are intact, normal muscle bulkiness, no involuntary movements,normal sensation to touch,
pain, temperature.

PLAN IN MALNUTRION
iv ampiclox 900mg tds 3 days
iv gentamycin 45mg od 5 days
oral cure apply 6 hourly 7days
syrp multivitamin 5mls od 7 days
zinc oxide apply 5 days
t. baclofen 5mg bd 7days
F75- 75mls every 2 hours

GENERAL EXAMINATION
alert, afebrile, not dyspneic, not pale, not jaundiced, not cyanosed, no Lower chest indrawing,

VITALS: PR 134bpm, RR 55cpm, Temp 38.5, SPO2 99% in RA

ANTHROPOMETRIC MEASUREMENTS
WEIGHT 10kgs
HEIGHT 84cm
WHZ: Median
MUAC: 14cm
normal anthropometric measurements

SYSTEMIC EXAMINATION

R/S, no grunting, symmetrical chest movement, no surgical or traditional marks, symmetrical chest
movements, no Lower chest indrawing resonant note on percussion, Vesicular breath sound with no
additional sounds.

P/A: Normal abdominal contour, not distended, moving with respiration, inverted umbilicus, not
tender on superficial palpation, no organomegaly on deep palpation, tympanic note on percussion,
normal bowel sound.

CVS: PR Regular rhythmic pulse, radial pulse synchronizes with other peripheral pulses, no raised
JVP, PMI at 4th left intercoastal space MCL, s1 and s2 heard with no additional sound.

CNS Alert, GCS 15, no sign of meningeal irritation,normal reflexes, no involuntary movements,
sensitive to pain
CRITIAL CASE
admitted the child in CRITICAL STATE from EMD ; RESUSCITATION WAS INITIATED ON
ADMISSION

INFORMANT (aunt) reports the child presented history of gradual onset of fever for the past 3 days
which were of gradual onset; progressive with time relieved with paracetamol initially.

she also reports developed acute onset of difficulty in breathing which was characterized with chest
indrawing and abnormal breathsound; the condition was preceeded by episodes of choking and
cough (productive cough with greenish sputum); condition was exacerbated following episode of
convulsion.

informant reports the child had multiple episodes of vomiting ; had 3 episodes at home; was
projectile vomiting; contained recently eaten food. the condition was progressive; prior admission the
child vomitted fresh blood mixed in vomitus. Had episode episode of passing loose stool x2

also developed sudden onset of multiple convulsions; tonic clonic with teeth biting and hyprertonia ;
convulsions were treated with anticonvulsants upto 2nd line

review of other system

CVS- NO history of bluish dislocation; had palmar pallor, no sudden LOC

CERTIFICATION

UNRESPONSIVE IN GASPING STATE; desaturating with peripheral cyanosis; pale; not jaundiced;
cool extremities with refill 3s

vitals
pr-140bpm; spo2-30% on O2; rr- 11cpm, temp-38.4
rbg - 4.4mmol/l

resuscitation was initiated; with positioning of the airway; cautioned deep suction with suction
machine approx. 100mls of fresh blood suctioned; intubation was attempted failed due to poor
visualization
given iv diluted adrenaline 0.3mg stat

resuscitation was attempted twice was unsuccessful;

at 02:20am

reviewed the child no spontaneous chest movement; no breathsound or heartsound on auscultation ;

pupils were fixed, dilated and non-reactive

death was confirmed and certified - relatives were informed

Immediate cause of death- HEMORRHAGIC SHOCK

precipitated cause of death- septicemia with DIC
underlying cause of death; SEPTICEMIA with ARDS
- SEVERE ANEMIA in failure due to UGIB (disseminated intravacular
coagulopathy)
FEBRILE CONVULSION

reviewed the patient from OPD, informant is her mother presented with fever for 1 day of gradual
osnent non progressive ass with vomiting 2 episode of recent eaten food materials, not ass with
abdominal pain, dirrhoea, also no any hx of discharge per ears, nose and eyes.

however had 1 episode of convulsion of generalized tonic clonic of less than a minute ass with eyes
rolling, froth saliva and LOC. went to tandale clinic and was given iv medication, not only that but also
mother reported no any family hx of epilepsy in the family, and last meal was 1 hour prio to an episode.

ROS-no any positve findings