Clinical meeting PaediatricsClinical meeting Paediatrics

1. Dr. KANTA HALDER
Resident (MD;Phase A),
General Pediatrics;
BICH.

2. Particulars of the patient
 Name: Khadiza.
 Age: 1 month 23 days.
 Sex: Female.
 Address: Uttara, Dhaka.
 Date of Admission: 08.10.2016.
 Date of Examination: 09.10.2016.

4. Chief Complaints
 Swelling of whole body for 7 days.
 Not growing well since birth.

5. History of present illness
According to the statement of mother, her
child developed swelling of whole body for 7
days which first involved both feet and then
gradually involved both legs and hands.
Mother also complained that her child is not
growing well in comparison to other peers of
same age group since birth. She has no H/O
fever, cough, respiratory distress or contact
with TB patient.

6. Cont..
With these complaints they consulted a local
doctor who referred the child to Dhaka Shishu
Hospital for further evaluation & better
management.

7. History of Past illness
She had H/O watery diarrhoea 20 days
back and was treated by a local doctor
with some oral medication, but mother
could not mention the names.

8. Birth History
Mother, a 18 years old malnaurished lady,
was on irregular antenatal check up.
Khadiza was delivered normally at 36 weeks
of gestation at a local clinic with low birth
weight, as one of the twin, without any
postnatal complication.

9. Feeding History
No prelacteal feed was given to her. She was
on breast feeding up to 15 days of age which
was inadequate in amount. Then breast
feeding was stopped and formula feed was
started with inappropriate dilution. Diluted
formula milk was prepared with ½ tsf milk
with ½ tsf sugar in 30 ml of water each time
and given about 5 times a day.

10. Feeding History (cont..)
• She received= (½ tsf milk + ½ tsf sugar) x 5
= (10 +10) x 5 = 100 kcal/day.
• Expected calorie requirement= (4.5x100) kcal.
= 450 kcal/day.
• Expected calorie deficit= (450 – 100) kcal.
= 350 kcal.
• Existed calorie deficit= (170 – 100) kcal.
= 70 kcal.

11. Developmental History
She has no neck control till date.
She can recognize mother’s lap.
Immunization History
She is not yet immunized.

12. Family History
She is the 1st issue of her non-consanguineous
parents. Her twin sister is suffering from similar
type of illness.
Socio-economic History
She belongs to a low socio-economic family.
Her both parents are garment workers. Their
monthly income is around 8,000 taka. They
live in a tin-shed house, use sanitary latrine
and drink boiled water.

13. General Examination
 Appearance: Conscious, irritable.
 Anaemia: Moderate.
 Jaundice:
 Cyanosis:
 Clubbing: Absent
 Dehydration:
 Edema: Grade ++.

14. Cont..
Hair: Normal.
Eye: Normal, no eye change.
Ear:
Nose: Normal
Throat:
Skin: BCG mark absent. No other skin
manifestation.
Lymphnode: Not palpable.

15. Cont..
Vital Signs:
Pulse: 120/min.
Respiratory Rate: 36/min.
Temperature: 98°F.

16. Anthropometry:
Cont..
Weight: 1.7 kg.
Lenght: 40 cm.
WAZ: - 5.0 (severely underweight).
LAZ: - 3.1 (severely stunted).
WLZ: - 3.0 (moderately wasted).
 OFC:

17. Systemic Examination
 Alimentary System:
 Mouth and Oral Cavity: Normal
 Abdomen:
Inspection: Abdomen is mildly distended,
flanks are not full, umbillicus is centraly
placed and inverted.

18. Palpation:
• Liver is palpable, 1 cm from right costal
margin along right mid clavicular line which
is non tender ,surface is smooth, regular
border. Upper border of liver dullnes is
present at right 5th intercoastal space.
• Spleen: Not palpable.
• Fluid thill: Absent.
Percussion: Shifting dullness absent.
Auscultation: Bowel sound present.
Cont..

19. Cont..
 Respiratory System:
Inspection: Respiratory rate - 36/min.
Palpation: Trachea is centrally placed.
Apex beat in left 4th ICS just lateral
to MCL .
Chest expansibility: Normal.
Vocal fremitus: Normal.
Percussion note: Normal.
Auscultation: Breath sound is vesicular, no
added sound.

20. Cont..
 Cardiovascular system:
Normal.
Other Systemic examination:
No abnormality.

21. Salient features
Khadiza, 1 month 23 days old non immunized
infant, 1st issue of her parents, one of the twin,
from poor socio-economic background,
presented with generalized oedema for 7 days
and failure to thrive since birth. She was born
prematurely with low birth weight and had
H/O a recent diarroheal episode along with
H/O gross feeding mismanagement from her
early life with existed calorie deficit of 70
kcal/day and expected calorie deficit of 350
kcal/day.

22. Salient features (cont..)
She is ill looking, irritable, moderately pale,
normothermic, having grade II oedema. She
is severely underweight, severely stunted and
moderately wasted. There is hepatomegaly
without ascites. Other systems reveal normal
findings.

23. Provisional Diagnosis
Severe Acute malnutrition (oedematous).

24. Investigations
Complete Blood Count :
• Hb: 8.2 gm/dl.
• WBC: Total count: 12,500/mm3.
Differential count:
o Neutrophil: 31%
o Lymphocyte: 65%
o Monocyte: 02%
o Eosinophil: 02%
o Basophil: 00%

25. Cont..
o RBC: Anisocytic anisochromic.
o WBC: Mature with above
distribution.
o Platelet: Adequate.
• Platelet: 296,000/mm3.
• PBF:

26. Cont..
 RBS: 4.7 mmol/L.
 S. Electrolytes:
Na+: 136.4 mmol/L.
K+: 4.4 mmol/L.
Cl-: 102.4 mmol/L.
 S. albumin: 13.6 gm/L.
 Blood C/S: Negative.
 Urine R/E: Normal.
 Chest X-ray: Normal.

27. Final Diagnosis
Severe Acute malnutrition (oedematous).

28. Management
Initial management (Stabilization phase):
 Prevention of hypothermia: by proper
clothing.
 Prevention of hypoglycemia: 50 ml bolus of
10% glucose by NG tube.
 Feeding:
• Restablishment of breast feeding.
• F-75 (without cereal) through NG tube:
15 ml 2 hrly (12 feed).

29. Management (cont..)
 Antibiotics:
• Inj. Ceftriaxone 150 mg once daily.
 Cap Vit-A: 50,000 IU P/O single dose.
 Tab Folic acid: 5mg stat and 1/4th tab daily.
 Syp Zinc: 2 mg/kg/day ( 1/3 tsf daily)
 Multivitamin drop without iron.

30. Management (cont..)
 Mother’s diet: High calorie & high protein
diet.
• Rice with fish/meat.
• 1 egg
• 1 banaba.
• 2 glasses of milk.
• 8 – 10 glasses of water.

31. Management (cont..)
Plan for Rehabilitation phase:
 Intensive feeding with breast milk. If not
possible, then diluted F-100.
 Syp. Iron 3mg/kg/day for 3month.
 Provide stimulation: Play and loving care.
 Preparation for discharge.
 Follow up.

32. Thank You