Welcome to Clinical Meeting

Presented By:

DR. MARIUM AKTER

Assistant Registrar (Pediatrics)
Sir Salimullah Medical College
Mitford Hospital, Dhaka
Particulars of Patient:

 Name : Samia
 Age : 3 Months
 Sex : Female
 Religion : Islam.
 Address : keranigonj.
 DOA : 04.12.2022.
 DOE : 05.12.2022.
 Informant : Mother
Chief Complaints:

 Swelling of both legs and hands for 15 days;

 Passage of loose stools for 5 days.

History of present illness:

According to the statement of informant mother, Samia was reasonably

well 15 days back. Then she developed swelling of both legs followed
by both hands. Mother also complained about passage of frequent
loose stools for 5 days which was 8-10 times/day, watery, foul smelling
not mixed with blood.
History of present illness (Cont’d.….):

For last 1 day purging Rate was increased about 15-20 times. On
query, mother gave h/o no urine output for last 8 hour. She had no h/o
fever, vomiting, cough, respiratory distress, jaundice, convulsion,
measles or contact with TB patient. With these complaints she was
visited by a local physician and was finally referred to this hospital for
better management.
History of past illness:
 Nothing significant.

Birth history:
 Mother was on regular antenatal checkup.

 He was delivered by NVD at term at a local clinic with average

birth weight.

 Perinatal and postnatal period was uneventful.

Feeding History:
Samia had history of prelacteal feeding with honey water. EBF was
given up to 15 days of age then feed with diluted (50ml+1-1.5 tsf milk)
formula milk was given upto 2 months of age. Then suji, mixed with
milk and sugar was started 4-5 times daily prepared one time daily
along with diluted formula milk in previous concentration 4-5 times a
day. Each time food is prepared by 2tsf suji + 1tsf milk+1/2 tsf sugar.
Feeding History cont….
So, calorie from formula milk (20x5) = 100 kcal
calorie from suji(40+20+20)= 80 kcal

180 kcal

calorie deficit (560-180) = 380 Kcal

Immunization History:
 Immunization is on going as per EPI schedule.

Developmental History:
 Age appropriate.
Treatment History:
 She was given ORS & syrup. Zinc for this illness for 4 days

Family History:
 2nd issue of non-consanguineous parents.

 Total family member 4.

 Age of last child is 2 year

Socio-economic History:

 His father is a businessmen & mother is a homemaker. Average

monthly income 10,000 tk.

 They lives in tin shed-house, use sanitary latrine, drinks supplied

water.
General Examination:
 Appearance : Chubby face , conscious but lethergic.
 Pallor : Mildly pale.
 Jaundice : Absent.
 Cyanosis : Absent.
 Clubbing : Absent.
 Koilonychia : Absent.
 Leukonychia : Absent.
 Edema : Grade 2
 Dehydration : Present
 Lymph node : Not palpable.
 BCG mark : Present.
General Examination (Cont’d.….):
 Skin Survey : Perianal excoriation was present
 Bony tenderness : Absent.
 Oral cavity : Angular stomatitis present at the angle of mouth.
 Tongue : Thrush present .
 Ear, Nose, Throat : Normal.
 Scalp and Hair : Hair thin , sparse , brown.
 Signs of meningeal irritation : Absent.
 Back and Spine : Normal.
 BSUA : Nil.
General Examination (Cont’d.….):
Regarding vitals :
 Periphery was cold
 Respiratory rate - 48 breaths /min.
 Heart rate - 165 beats/min.
 Capillary refilling time : 4 seconds
 SPO2 - 89% in room air.
 CBG – 2.7 mmol /l.
Anthropometric measurement:
 Weight – 4.6 kg .
 Length - 59 cm.
 OFC - 40 cm.( just on 50th centile).
Anthropometric measurement:

Parameter Z- Score Comment

WAZ -1.4 Marginally underweight.

LAZ -1.26 mild stunting.

WLZ -2.5 Moderately wasted

Systemic Examination-
Alimentary system:
Oral cavity: Angular stomatitis at the angle of mouth.
Tongue : Oral thrush present.

Inspection:
 Shape: Normal.
 Umbilicus: centrally placed ,inverted .
 Flanks were not full.
 No visible peristalsis/ scar mark/ engorged vein.
Alimentary system (Cont’d…..):
Palpation:
 Abdomen : Soft.
 Liver: palpable about 3 cm from rt. costal margin along mid
clavicular line, smooth surface, non-tender, firm in consistency,
upper border of liver dullness present in 4th ICS.
 Spleen: not palpable .
 Urinary bladder: not palpable.
Alimentary system (Cont’d…..):
Percussion:
 Fluid thrill : Absent.
 Shifting dullness : Not present.

Auscultation:
 Bowel sound: Present.
Respiratory system:
Inspection:
 Respiratory rate- 48 breaths/min.
 Shape of chest: Normal .
 There was no suprasternal, intercostal, sub costal recession.

Palpation:
 Trachea- centrally placed.
 Apex beat- Lt. 4th ICS medial to mid- clavicular line.
Respiratory system (Cont’d…..):
On percussion:
 Resonant.

On auscultation:
 Breath sound- Vesicular .
 No added sound.
Cardiovascular System:
Inspection:
 No precordial bulging.
 No visible pulsation, scar mark engorged vein.

Palpation:
 Apex beat: Lt. 4th ICS, medial to mid- clavicular line.
 Left parasternal heave: Absent .
 Thrill: Absent.
 Palpable P2: Absent.
Cardiovascular System (Cont’d…..):
Auscultation:
 1st & 2nd heart sound are audiable at all 4 cardiac area.
 No murmur.
Nervous system:
Higher psychic function:
 Appearance- Irritable ,conscious .
Cranial nerve examination: Intact as far I could examine
Motor function:
 Bulk of muscle- Normal in all 4 limbs.
 Tone of muscle- Normal at all 4 limbs.
 Power of muscle- 5/5.
 Jerk-normal.
Sensory function: intact.
Others systemic examinations:

Revealed no abnormality.
Salient Feature:

Samia, 3 months old girl, 2nd issue of non-consanguineous parents,

belongs to low socio-economic background, immunization is on going
as per EPI schedule, hailing from Keranigonj got admitted with the
complaints of swelling of both leg and hand for last 15 days and acute
watery diarrhea for 5 days with urinary suppression for last 8 hour;
without having no history of fever, cough, vomitting respiratory
distress, jaundice, convulsion, measles, contact with TB patient.
Salient Feature (Cont’d…..):

Gross feeding mismanagement was present since birth and now daily
calorie deficit is 380 kcal. Samia was found lethargic, edematous,
mildly pale, dehydrated, hypoglycaemic with features of shock having
thin sparse hair , normal eyes, oral thrush, angular stomatitis &
perianal excoriation. He is mildly underweight, mildly stunted,
moderately wasted. She has mild hepatomegaly without ascites. Other
system examination reveals normal.
Provisional Diagnosis:
Severe acute malnutrition with Diarrhoea with Shock
Points in Favor – Severe acute
malnutrition (edematous):
From history:
 Swelling of both legs & hands.
 Gross feeding mismanagement.
 Low-socioeconomic background.

From examination:
 Grade 2 edema.
Investigation profile:
Patient’s Value Reference Value
CBC Hb- 8 gm /dl. 12.5 gm/dl.
WBC – 13,300/cmm 4,000– 11,000/ cmm
N-49%; L- 41%. 40-75%,20-50%
MCV – 70.8 fl. -
MCHC – 21.5 pg. 76-96 fl
MCHC – 30.4gm/dl 27-32 pg
RDW- 14%. 32-36 gm/dl.
Platelet- 2,70,000/ cmm. 11.6-14%
1,50,000-4,50,000/ cmm.
Investigation profile (Cont’d…..):

Patient’s Value Reference Value

S.Electrolyte Na- 134 meq/l. 135-146 meq /l.
K- 2.8 meq/l. 3.5-4.5 meq /l.
Cl – 107 meq/l. 97-106 meq /l.
Urine R/E Epithelial cell- 2-4/HPF.
RBC- Nil.
Pus cell- 1-2/HPF.
MT No induration after 72
hours.
Chest X-ray A/P view:
Final diagnosis:
Severe acute malnutrition with diarrhoea with shock.
Management:
Management of shock:
 Oxygen inhalation
 10% glucose I/V;5ml/kg
 Infusion cholera saline with 5% glucose;20ml/kg over 1hour
 Again cholera saline with 5% glucose 20ml/kg was given over 1
hour.
 Kept the baby warm with proper clothes.
Management (Cont’d…..):
 Resomal 25 ml half hourly for 2 hours,then alternate hours with F-
75 diet for 10 hours.
 (F- 75)
38ml every 2 hourly( total 12 feed including day and night).
 Inj. Ceftriaxone(75mg/kg/day)
 Inj. Gentamycin( 7.5 mg/kg/day…………once daily).
(added after urine output)
 Cap . Vitamin-A(1,00,000 IU)……..1Cap P/O stat.
 Tab. Folic acid (5 mg)
1 tab P/O on 1st day stat followed by 1 mg daily.
Management (Cont’d…..):
 Syrup. Zinc……….2mg/kg/day P/O 12 hourly.
 Syrup. Potassium chloride….4mmol/kg/day P/O 12 hourly.
 Inj. MgSO4…….. 0.1 ml/kg/day I/M once daily for 7 days.
 Syrup . Multivitamin…….2.5 ml P/O once daily.
 Zinc oxide- cream…..apply over the perianal area 8 hourly.
 Nystatin oral drop 15 drops over tongue …..12 hourly.
Follow up:
Date Subjective Objective Assessment Plan

08.12.22 No new Edema-+ Improving. Start 3 hourly

(D-4) complaints. Wt-4.5 kg feed.
R/R-40br/min.
H/R-126b/min.
No diarrhea
U/O-adequate
11.12.22 No new No oedema Improving. Start 4 hourly
(D-7) complaints. Wt-4.2kg. feed.
R/R-38br/min.
H/R-124b/min.
13.12.22 No new WT-4.2 kg. Improving. Start F-100 4
(D-9) complaints. hourly feed.
Follow up cont….
Date Subjective Objective Assessment Plan

15.12.22 No new Wt- 4.23 kg ↑ Improving. Increase 10

(D-11) complaints. (7gm/kg/day) ml/kg.

16.12.22 No new WT-4.27kg.↑ Improving. Increase

(D-13) complaints (9gm/kg/day) 10ml/kg.

17.12.22 No new Wt-4.32kg ↑ Improving Plan for

(D-14) complaint (11gm/kg/day) discharge
Plan during discharge:
 Iron syrup: 3mg/kg/day….start after 1 week for 3 months.
 Provide sensory stimulation and emotional support.
 Prepare for discharge.
 Follow-up.
Follow up

 1st visit-at 1week after discharge in treated health facility or nearby

health facility
 2nd visit-2 week
 3rd visit-1month
 4th visit-3 month
 Then every 3 months until WHZ becomes >1
THANK YOU
ALL