Patient Data Sheet

Module: Gastrointestinal System / Nutrition

Problem: 2.16 -2020

Nellie, the 18 month old child who is underweight

Presenting complaint:
While being visited by a Zone Nurse yesterday to update her immunisations, Nellie, an 18-month-old child,
was found to be underweight. The nurse referred her to the Health Centre to be checked.

History of the presenting complaint, at the health centre:

 While visiting Nellie’s home yesterday to give her the immunisations that she had missed, the Zone
Nurse found that Nellie was underweight when she measured her weight with the scale, and
recommended that mother bring her to the health centre.
 Nellie's mother, Ofa, was surprised: she says that Nellie has been well apart from an occasional cold.
 In answer to specific questions, mother says Nellie has had diarrhoea twice in the past 3 months.
 The first time it lasted a few days, and she got better without any treatment.
 Now Nellie has diarrhoea again: it has lasted for more than two weeks and she hasn't got better.
 The stool is watery, without blood or mucus. She has been having about five stools in a day.
 She has no vomiting. She has not had fever. She has been drinking lots of water as she seems
thirsty.
 Ofa and her mother are the main caretakers. When Ofa goes to work during the day, grandmother
looks after Nellie.

Feeding: Nellie eats what the family eats. (The following details to be provided if the students ask):
 Ofa breast-fed Nellie for two months. She then gave "Red Cow" brand powdered milk, when she went
back to work. She stopped giving Nellie the milk at about 8 months of age, as it was too expensive.
 The family eats taro, cassava, breadfruit, and taro leaves. Once or twice a week they have tinned meat
or fish. Several times a week they have papaya or bananas.
 Nellie eats mostly cassava and tea, rarely anything else, as she seems to prefer only cassava and tea.
Her mother says she doesn't eat much these days, and refuses to eat most of the food given to her.

Review of systems: No cough or shortness of breath. No vomiting. No fever.

Past Medical History: No admissions to hospital. No illnesses (apart from those mentioned above).

Allergies: None known Medications: None

Paediatric Hx: Nellie was born in hospital. Her birth-weight was 2.9 kg. Mother was un-booked, but says
the pregnancy was normal, the delivery was uncomplicated. Nellie had no problems as a newborn or
infant.

Immunisations: Not up to date (checked on MCH card) – she did not receive her measles immunisation.

MCH card: (Information to be provided to the students if they request): Nellie has not been brought to the
MCH clinic during the past 5 months. Her previous weights have been recorded as follows:

Birth (2 Feb 2019) 2.9 Kg July 4.7 Kg

2nd March 3.0 Kg August 5.2 Kg
2nd April 3.4 kg October 5.8 Kg
21 May 3.6 Kg December 2019 7.0 Kg
June 3.9 Kg October 9 2020 7.5 Kg

Developmental Hx: Nellie walks and uses some words. (Details to be provided if students request
them).
 Nellie rolled over at 4 months, she crawled and sat up herself at 8 months, she pulled herself up to
standing at 12 months, she started walking at 14 months, and was very active then.
 She hasn't walked since she got diarrhoea two weeks ago. Mother says she has not smiled for a
week.

Social History:
 Ofa is 20 years old and unmarried. She attended school up to Form 4.
 She lives with her parents and her 3 younger siblings in a 3-bedroom house. Inside toilet, piped water.
 She works in a garment factory. She often comes home very late in the evening, as she enjoys
spending the evening at the nightclub with her friends.
 Ofa’s father is a casual labourer, her mother does domestic duties at home.
 Nellie is Ofa’s first child. Ofa says she is now about 3 months pregnant.

PHYSICAL EXAMINATION:
General appearance: Nellie is pale and appears thin. She sits alone on the cot; she appears sad and
apathetic, uninterested in what is happening around her. She does not look at anyone directly, and just
looks down at the floor. When approached, she turns away and cries. She does not reach out for her
mother or hug her for support. Mother says this is the way she has been at home.
Vital signs: Temperature 36.6 C (ax); Pulse 114/min, regular. Resp rate 18/min.
Weight: 7.9 kg Length: 80 cm Head circumference: 46 cm Blood glucose : 3mmols/L
HEENT: Her anterior fontanelle is closed.
 She has thin coarse hair. Some of her hair is not black, but is lighter-coloured, brown and yellow.
 Her eyes are not sunken, and she has tears when she cries.
 Her conjunctivae are pale. She has Bitot spots on the medial aspect of the conjunctivae.
 There are cracks at the corners of her mouth. Her mouth is moist; her tongue is red, smooth and
shiny.
Chest / Respiratory: Symmetrical on inspection. Clear on auscultation, no wheezes or crackles heard.
Cardiovascular: Normal first and second heart sounds. No murmur. Capillary refill is < 2 seconds.
Abdomen: Mildly distended, no palpable masses. No liver or spleen enlargement. Normal bowel sounds.
Perineum: Normal female genitalia. Her perianal area is red and excoriated.

Extremities: Her buttocks have decreased subcutaneous tissue. Her buttocks and legs have decreased
muscle mass. There is oedema over the tibias and the dorsum of her feet.
Skin: Her skin is very thin, like parchment. There are some darkly hyperpigmented areas, 2-3 cm
diameter, over her trunk and extremities, which are flaking. Her skin pinch goes back quickly.
Neurological Examination: Nellie does not bear weight when placed in standing position. Muscle
strength is 4/5 in all extremities. Deep tendon reflexes are normal, Babinski is plantar flexion. She
withdraws to pain.

INVESTIGATIONS:
 FBC: Hb: 7.2 gm/dl Hct: 27% MCV: 56 fl WBC: 8,300/mm3: 42%N, 55%L, 3% Eos
 Glucose: 4 mmol/l Total protein: 32 grams/l Albumin: 15 grams/l
 Electrolytes: Na - 135 mmol/l; K - 2.3 mmol/l; Urea - 4 mmol/l; Creatinine - 35 mol/l
 Midstream urine (MSU): Dipstick: protein and glucose nil.
Microscopic: 0 WBC, 0 RBC per HPF.
 Stool exam: Hookworm, ascaris, and trichuris ova seen. No WBCs. No mobile trophozoites or cysts.
 Chest X-ray: Normal
 HIV test - negative

ASSESSMENT:Malnutrition, kwashiorkor type. Diarrhoea, no dehydration. Weakness due to hypokalemia.

Wasting, no stunting :
Her weight-for-age is < 5th centile (equivalent to the weight of a 7 month old).
Her height-for-age is at the 25th centile. Her weight-for-height is < 5th centile.

MANAGEMENT: Nellie was referred to hospital for admission.

 She was given vitamin A 100,000 units orally immediately on admission, and again the following day.
 An anti-helminthic (Pyrantel) was given. Oral iron supplements and multivitamins were given daily.
 She was given a diet of local food, which included local starches, green vegetables, fish, and eggs.
 She was given bananas to treat her low potassium.
 Nellie refused to eat most of what was provided. A nasogastric (NG) tube was placed to assist with
feeding, which irritated her at first, as she tried to pull it out several times. After the first day, however,
she seemed to forget that the tube was in place.
 Blended food was given in the NG tube, and her mother was told she could continue to give her food
to eat by mouth, even with the tube in place.
 Nellie was weighed and her weight recorded on alternate days.

OUTCOME:
 By the end of the first week in hospital, Nellie had started to eat some food on her own.
 By day 10, her weight had decreased to 7 kg. Oedema resolved. Her legs were noted to be quite thin.
 After 2 weeks in hospital, her weight was 7.5 kg. The NG tube was removed as she seemed to be
eating better on her own. She was seen to be smiling for the first time.
 It was explained to Ofa and the family that Nellie's problems were caused by the fact that she ate only
cassava and tea. Ofa and the family were counselled on local foods which they could prepare for her.
 Nellie was discharged home after 3 weeks in hospital, for follow-up visits at the Health Centre.
 Ofa was scheduled for her booking antenatal clinic visit at the Health Centre. During her booking visit,
the nurse spoke to her about family planning options she could consider after the delivery.