CLINICAL CASE “CAMILA” - CHILD CARE FROM 2 MONTHS TO 5 YEARS

PRESENTED BY:

Yaselly Giraldo Mejia

Elizabeth Giraldo Restrepo
Snai González Vidal
Valeria Guzman Martínez
Sebastián Herrera Rodríguez
Aida Inciarte Fonseca

PRESENTED TO:

MD. GRACIELA MARTINEZ

METROPOLITAN UNIVERSITY

PEDIATRICS C

MEDICINE X

2022 - II
 – CHILD CARE FROM 2 MONTHS TO 5 YEARS

DATE: DAY MONTH YEAR 2022 HOUR: CLINICAL HISTORY NO. xxx
INSTITUTION: XXXXXXXXXXXXXXXXXXX EXTERNAL CONSULTATION EMERGENCIES: X
MUNICIPALITY: BOGOTA INITIAL CONSULTATION CONTROL
NAME: CAMILA AGE: 20 MONTHS SEX (F) X (M) __
COMPANION'S NAME RELATIONSHIP
ADDRESS LANDLINE/CELL PHONE XXXXXXXX
REASON FOR CONSULTATION AND CURRENT ILLNESS :
“She has a cough and looks bad” Female 20-month-
old older infant who goes to the emergency room accompanied by a caregiver for presenting a
clinical picture of approximately 24 hours of evolution characterized by cough and respiratory
distress, reason for which she consults

IMPORTANT PATHOLOGICAL BACKGROUND: 34 WEEKS PREMATURE

How was the pregnancy? And how long? How was the delivery?
Birth weight gr. HEIGHT at birth cm. Did you have any neonatal problems? HOSPITALIZED FOR 3 WEEKS
Previous illnesses and hospitalizations: MILD INFLUENZA PICTURES

TEMPERATURE __C FC /min. FR 133 /min. SIZE 90 cm. WEIGHT 12 Kg PC: cm. BMI: 114.8
CHECK FOR SIGNS OF DANGER IN GENERAL
Can't drink or breastfeed lethargic or unconscious VERY SERIOUS ILLNESS
throw up everything seizures OBSERVATIONS:

DO YOU HAVE A COUGH OR DIFFICULTY BREATHING? YES X NO SEVERE CROUP

Since 1 days breaths per minute 39 Rapid Breathing First SEVERE OR HIGH-
episode of wheezing: YES x NO Subcostal retraction Sa0two<92% (90% height RISK
>2,500msnm)Recurring wheezing: YES NOT x Supraclavicular retraction BRONCHIOLITIS
Flu symptoms last 3 days: YES x NO stridor wheezing SEVERE OR SEVERE WHEELING OR
History of prematurity: YES X_ NO Apnea SEVERE ASTHMA
Inability to speak or drink OBSERVATIONS: MODERATE CRUP
Sleepy Confused Hectic BRONCHIOLITIS WITH
HISTORY OF ALLERGY
WHEELING OR
MODERATE ASTHMA
MILD CRUP
BRONCHILITIS
WHEELING OR MILD
ASTHMA
SEVERE PNEUMONIA
SUSPECTED SEVERE
WHOOPING COUGH
PNEUMONIA
SUSPECTED WHOOPING
COUGH
COUGH OR COLD
DO YOU HAVE DIARRHEA? YES NOT X
SEVERE DEHYDRATION SOME
lethargic or comatose DEGREE DEHYDRATION HIGH
restless or irritable RISK DEHYDRATION
Hollow eyes WITHOUT DEHYDRATION
Drinks poorly or cannot drink SEVERE PERSISTENT
DIARRHEA PERSISTENT
# Vomiting in the last 4 hours. #Diarrhea in the last 24
hours. Baby eagerly thirsty DIARRHEA DYSENTERY
#Diarrhea in the last 4 hours. Fold skin: immediate Slow Very slow
OBSERVATIONS:

HE HAS FEVER? YES NO X

Since days Rigidity nape Appearance seriously ill If HIGH RISK FEBRILE DISEASE
>5 days: Every day YES NO manifestations of bleeding INTERMEDIATE RISK OF
Appearancetoxic FEBRILE DISEASE
Fever >38°C YES NO Community response: Normal Inadequate Without response LOW RISK FEBRILE DISEASE
Fever >39°C YES NO Skin: pale mottled Cinderella Blue
Lives or visited in the last 15 days Generalized skin rash Pain abdominal Dengue Zone MALARIA COMPLICATED
(height <2,200m) no headache Myalgias: X Arthralgias Pain retro eye MALARIA
Malaria Zone: Urban Rural Prostration P. tourniquet (+) Lipothymia hepatomegaly Diuresis
diuresis: YES NO rapid pulse and fine Capillary refill>2 sec. ascites
LABORATORIES: LC leukocytes >15,000 <4,000 neutrophils >10,000 Platelets <100,000 SEVERE DENGUE
Partial Urine compatible with infection Drop coarse positive DENGUE WITH ALARM
OBSERVATIONS: SIGNS
PROBABLE DENGUE
DO YOU HAVE A HEARING PROBLEM? YES NOT x MASTOIDITIS
Do you have ear pain?: YES NO Swelling painful behind the ear CHRONIC OTITIS MEDIA
Do you have suppuration?: YES NO Does Days Red and Bulging Eardrum RECURRENT OTITIS MEDIA
Number of previous episodes: in months ACUTE OTITIS MEDIA
suppuration of ear DOES NOT HAVE OTITIS
OBSERVATIONS:
DO YOU HAVE A THROAT PROBLEM? YES x NO
VIRAL
Do you have a sore throat?: YES NO nodes of the neck enlarged and painful
PHARYNGOTONSILLITIS
OBSERVATIONS Erythematous tonsils STREPTOCOCCAL
Whitish-yellow exudate on tonsils PHARYNGOTONSILLITIS
DOES NOT HAVE
PHARYNGOTONSILLITIS
 IMCI – CHILD CARE FROM 2 MONTHS TO 5 YEARS
NEXT, CHECK YOUR ORAL HEALTH FACIAL CELLULITE
Do you have pain when eating-chewing? YES NO Inflammation sore
lip does not involve groove SERIOUS ORAL DISEASE
Do you have tooth pain? YES NO redness Inflammation ORAL TRAUMA
gum Located
Trauma to the face or mouth? YES NO widespread STOMATITIS
Do parents/siblings have cavities? YES NO Contour deformation
gum Exudate-pus DENTAL AND GINGIVAL
When do you clean your mouth? Tomorrow yes NO vesiclesUlcers Plaques: gum tongue DISEASE
Noon palate: YES NO Night: YES NO Fracture Mobility
Displacement HIGH RISK OF ORAL DISEASE
How do you supervise cleanliness? cleans his Extrusion Intrusion LOW RISK OF ORAL DISEASE
Avulsion Teeth: YES NO Child only YES NO Wound:
buccal mucosa gum language
What do you use? Brush: YES NO Stains white cafes
Cream: YES NO Silk: YES NO Cavities cavitational License plate bacterial
Do you use a pacifier or bottle? YES NO
OBSERVATIONS
When was the last consultation od
CHECK GROWTH: SEVERE ACUTE MALNUTRITION
Visible emaciation YES NO Weight/Age: SD: <+1 AND >-1 <−3 Severe global malnutrition MODERATE ACUTE
MALNUTRITION
Edema in both feet YES NO (Only in children under 2 years) <−2 to ≥−3 Global malnutrition RISK OF ACUTE MALNUTRITION
Appearance: <−1 to ≥−2 Risk ofMalnutrition RIGHT WEIGHT FOR SIZE
≤1 to ≥−1 Adequate weight for RISK OF OVERWEIGHT
age BMI/Age: OF Size/ Age: SD: <-1 AND >-2 <−2 Chronic malnutrition either OVERWEIGHT
>2 Obesity Delay increase OBESITY
DELAY IN SIZE
>1 to ≤2 Overweight ≥−2 a <−1 DNT risk with low P/T
RISK OF SHORT HEIGHT-FOR-
≥−1 Appropriate height/age AGE
Weight Trend: Ascending Weight/Height: SD: <-1 and >-1 <−3 Severe RIGHT SIZE FOR AGE
Acute Malnutrition RISK OF DEATH DUE TO
Horizontal ≥−3a<−2 Acute DNT-Low Weight/Height MALNUTRITION
Falling ≥−2 a <−1 DNT risk with low P/T
≥−1 to ≤1Adequate Weight for Height
OBSERVATIONS: >1 to ≤2 Overweight
>2 Obesity
CHECK IF YOU HAVE ANEMIA
Have received iron in the last 6 months: Pallor palm grove: intense Mild SEVERE ANEMIA
When? How long? Conjunctival pallor: intense DOES NOT HAVE ANEMIA
OBSERVATIONS:
NEXT, VERIFY IF YOU HAVE ABUSE
How did the injuries occur? Skull injuries:Fractures - Bruises
retinal hemorrhages
Does the child report abuse? YES Nope Burns: Areas covered by clothing
Which? Physical Sexual Neglect Pattern symmetrical, well demarcated VERY SERIOUS PHYSICAL
boundary ABUSE
Does a witness report abuse? Yes Nope Of note the object with which it was
burned
Which? Physical Sexual Neglect In back, back of hands or buttocks
SEXUAL ABUSE
Who? Ecchymosis - Hematomas - Lacerations -
Is there inconsistency to explain a bites - Scars away from bone prominence Significant trauma? YES
NO With pattern of the aggressor object – Different
evolution
PHYSICAL ABUSE
Is there incongruence between injury - age In Non-Walking Children – Suggestive of Maltreatment
- child development? Yes Nope Fractures: Ribs–Long Bones - Spirals
Are there different versions? Yes Nope Oblique - Metaphyseal–Breastbone
Is the consultation late? Yes Nope Scapula - Less than 5 years SUSPECTED SEXUAL ABUSE
How often are you forced to Visceral trauma Trauma serious
Hit your son? Injury suggestive physics
How disobedient is your child? Vaginal or anal bleeding traumatic
are you forced to hit him? Trauma genital: Acute laceration or ecchymosis EMOTIONAL ABUSE,
hymen Abnormal behavior of parents: Laceration perianal from sphincter NEGLECT OR
Desperation - impatience - intolerance Absence hymen Hymen scarred ABANDONMENT
Aggressiveness in the query Navicular scar Anus expanded
Is the child neglected is his health? Finding semen genital discharge
Yes Not By: Body strange in vagina or anus THERE IS NO SUSPECT ABUSE
Is the child careless in his hygiene? Vesicles or warts on the genitals
Protection –Food – Street child Sexual play - mouth on genitals Factor Risk:
Disabled HIV - Gonorrhea - Syphilis - Trichomonas
vaginalis>1aHyperactive, Chlamydia Trachomatis >3 yrs. - Condylomatosis
Abnormal attitude of the child? Yes Nope
Fearful - Withdrawn - Adult rejection - Depressed - Avoid eye contact - Sleep disorder - Eating disorder -
Psychosomatic problems - Regressive behaviors - Stalled development Domestic violence - Chaotic family -
Addicted caregivers
OBSERVATIONS
 IMCI – CHILD CARE FROM 2 MONTHS TO 5 YEARS
NEXT, ASSESS THE DEVELOPMENT LIKELY DELAY
Do you have any relevant background? Perform 1 2 3 4 conditions for the age DEVELOPMENT RISK
For development; Absence of 1 2 3 4 conditions for the age PROBLEM
Absence of 1 2 3 4 conditions from the previous group DEVELOPMENT
Has any risk factor: Head circunference: cm OF <-2SD >+2SD NORMAL DEVELOPMENT WITH
Phenotypic alterations: RISK FACTOR
OBSERVATIONS: NORMAL DEVELOPMENT
VERIFY VACCINATION HISTORY (Mark with an X the doses already applied)BCG 1 Pending vaccinations;
Hepatitis B: RN 1 two 3 TPD: 1 two 3 R1 R2
VOP 1 2 3 R1 R2 Haemophilus influenza type b: 1 two 3 R1 R2
Rotavirus: 1 2 Streptococcus pneumoniae: 1 two 3 Upcoming Vaccines:
Influenza: Last Dose: SRP: 1 2 Yellow Fever: Age
Other vaccines:
To the (Months years)
COMPLETE PHYSICAL EXAM: OTHER PROBLEM DETECTED
DIAGNOSIS:

EVALUATE THE NUTRITION OF ALL CHILDREN UNDER 2 YEARS OF AGE and those classified as ANEMIA PROBLEM DETECTED:
and/or ANY OF THE GROWTH DISORDERS
Do you receive breast milk? How many times in 24 hours? Do you breastfeed
at night?
Is the milk expressed? How do you save and manage it?
Does the child under 6 months receive other milk or food? Which? How
manytimes? With what? Who feeds him?
The child older than 6 months receives:
How many meals and snacks did you receive yesterday?
What size are the portions you received yesterday?
How many thick consistency meals did you receive yesterday? RECOMMENDATIONS:
Did you eat food of animal origin yesterday? Meat / Fish / offal / poultry / egg
Did you eat dairy products yesterday?
Did you eat legumes or seeds yesterday?
Did you eat red or orange vegetables or fruits AND dark green leaves yesterday?
Do I add a small amount of oil to the child's food yesterday?
Who gave the child the food yesterday?
Does the child eat from his own plate or does he eat from the family pot or plate?
Does the child receive any vitamin and mineral supplementation?
IF YOU ARE SICK: What have you eaten during the illness?

IF OBESE: Are parents or siblings obese?

Does the child exercise?
Are you attending a nutritional program?

OBSERVATIONS:
 IMCI – CHILD CARE FROM 2 MONTHS TO 5 YEARS

1. Warning
signs: DIAGNOSTICS CODE
FEVER APPEARS, CONVULSIONS, 1. INFANT WITH SEVERE CROUP
2. INFANT WITH SEVERE BRONCHIOLITIS
VOMITS ALL, CANNOT TAKE OR
DRINK FROM THE CHEST,
LETHARGY OR UNCONSCIOUSNESS,

2. When to come back for a

TREATMENT
consultation
(Describe treatment plan, medications, dosage and timing, and
Control: 2 DAYS
anyadditional recommendation needed)

Where: 1. Hospitalize in the pediatric ward (isolation by contact and

____________________________________________________________
3. When to return to the drops)
____________________________________________________________
Well Child or Growth and 2. Suspend orally
____________________________________________________________
Development consultation: 3. Warm, humidified oxygen 2 L/minute by nasal cannula if
____________________________________________________________
saturation is <92%
____________________________________________________________
4. Canalize peripheral vein
____________________________________________________________
4. Referred to query from: 5. DAD 5% Sodium chloride 15 mL, potassium chloride 5 mL (to
____________________________________________________________
meet basal needs)
____________________________________________________________
6. Dexamethasone IM 0.6 mg/kg maximum 10 mg
____________________________________________________________
7. Nebulization of oxygen with adrenaline (dilute 1 mL of
____________________________________________________________
adrenaline in 9 mL of distilled water, from the dilution
____________________________________________________________
5. Recommendations for development:
administer 2.5 mL in nebulization and monitor)
____________________________________________________________
8. Acetaminophen 10 mg/kg IV every 6 hours in case of fever
____________________________________________________________
9. Request neck X-ray
____________________________________________________________
10. Request complete blood count, ionogram, blood glucose
____________________________________________________________
11. urine output control
____________________________________________________________
6. 12. Control of vital signs and notify changes
Recommendations of good treatment: ____________________________________________________________
13. Teach the mother about warning signs to return
____________________________________________________________
immediately
____________________________________________________________
14. Advise the mother on proper nutrition
____________________________________________________________
15. Ensure growth and development consultation
____________________________________________________________
16. Continue with vaccination schedule as appropriate
____________________________________________________________
7. Received Vitamin A in the last 6 m.:
____________________________________________________________
Yes Nope Next dose:
____________________________________________________________
____________________________________________________________
8. Received Albendazole in the last 6 m.: ____________________________________________________________
Yes Nope Next dose: ____________________________________________________________
____________________________________________________________
____________________________________________________________
9. Received Iron in the last 6 months:
Yes Nope When ____________________________________________________________
____________________________________________________________
____________________________________________________________
10. Requires receiving Zinc: Yes Nope
For how long? Start