Malnutrition case

presentation

Group 1
• Tasneem Abdallah Hamaden Mohamed a 9 month old female from ‫ اـالنـقـاذ‬.
Informant was taken from her mother.
• Admitted on 19th of October 2020.
• Complaining of diarrhea for 2 weeks and fever for 3 days.

• HPI:
The condition started 2 weeks prior to admission with diarrhea, watery , 3
– 4 times per day not containing mucus or blood , large in amount not
offensive. Then developed high grade fever , intermittent not associated with
rigors or convulsions . There is abdominal distention and loss of weight , no
vomiting or yellow discoloration of sclera , good appetite no mouth ulceration .
• Systemic review:
Cardiopulmonary : No SOB , no cough , no syncope or abnormal sound
as wheeze or stridor.
CNS : No loss of consciousness or convulsions, no headache nor signs
of cranial nerve palsy , also no signs of increase intracranial pressure
neither motor or sensory defects and sphincter are intact.
Muscloskeletal : she has musle wasting , no joint swelling or restriction
of movement .
Genitourinary: urine is normal in amount and color and frequency, no
crying during micturation.
Dermatology : no change in pigmentation, no rash or itchiness.
• PMH : pt has past history of recurrent gastroenteritis and received syrups and
improved , has past history of hospitalization at age of 5 month mostly because
of pneumonia and she received medications and improved , no history of blood
transfusion ,no history of surgical operation, no history of jaundice or infectious
diseases,.

• Development history :
prenatal : mother had good antenatal care, received folic acid and iron , had a
normal pregnancy without complications or illnesses and was not exposed to
radiation.
Perinatal : The baby was term , delivered by normal vaginal delivery at home
conduct by a skilled midwife , with no complications, cry immediately normal
weight and color had immediate breast feeding , had no infection, pass
meconiumin in first day.
 Postnatal :
smile at 6 weeks
head support at 3 month
sit with support at 5 month
sit without support at 6 month
she started to crawl at 7 month

• Vaccination history : fully vaccinated up to date.

• Nutritional history: not exclusive breast feeding, poor
complementary feeding composed of ( ‫س كـاسترد‬ ، ‫بــــطاط‬،‫ )رز‬.from 2-
3times per day. The mother feeds her byherself and alone. She is now
breast feeding 5 times per day.

• Family history: no family history of similar condition. No history of

genetic disorder .there is second degree consagunity.
Family pedigree:

22years 40years

9 month
• Social history: the mother is illiterate housewife, the father is
educated till primary school an unskilled free worker . They live in
there own house 2 bedroom and 2 separated bathrooms have a
kitchen, no water or electrical supply, no pets . No health insurance.

Drug history: pt is not allergic to any drug known by her mother, she is
not on any long term medication, now on formula milk 74ml ,
RESOMAL , tonics.
 On examination:
• By inspection: pt is conscious, looks ill lying flat not paled or jaundiced has
a nasogastric tube.
• Vital signs : heart rate 139 , RR 32 , temperature 36.9°
Anthropometric measurements: head circumference 43cm , chest
circumference 41.5 cm , midarm circumference 10cm , has loss of
subcutaneous fat .
• Head : no palor , no jaundice, no mouth ulceration, normal mouth cavity ,
no buccinator wasting , no ear discharge.
• Neck : no raise in JVP , no lymphadenopathy, no thyroid enlargement.
• Hand : not pale.
• Cardiopulmonary: by inspection normal chest contour and movement,
no visible pulsation ,no dilated veins , no surgical scar ,
thoracoabdominal respiration, RR normal .
by palpation: apex beat felt at , central trachea , no tenderness.
by auscultation normal first heart sound no murmur or added sound,
normal air entry vesicular breathing no added sounds.
• Abdominal : by inspection no abdominal distention, move with
respiration, umbilical is inverted, no dilated veins or surgical scars.
by superficial palpation abdomen is soft not tender , no superficial mass,
no rigidity. Deep palpation not done .
• CNS : pt is conscious, not irritable , was playing .
• Investigation :
CBC : anemia, leukocytosis, ESR
Random blood glucose
BFFM -ve
Serum albumin
Urine general
Stool general
Chest X-ray for t.b , pneumonia
Blood culture if suspect septicemia
• Diagnosis :
• According to cardinal signs found :
1. Irritable
2. Wasting
3. Growth failure
4. No odema
PEM MARSMUS
due to:
5. Not exclusive breast feed
6. Recurrent gastroenteritis
7. Poor complementary food
8. poor socioeconomic status
Management
• Addmission
• Cannula 22
• Nasogastric tube
• Give formula of milk 74ml every 2 hours
• Give penicillin every 6 hours
• Give gentamicin 17ml every 8 hours
• Give RESOMAL
• Give Zink syrup
• Give multivitamins + folic acid one tab daily