CASE PRESENTATION

BY :

HIMANSHU SAROJ (36)

JYOTI KUMARI(37)
KANSYA SINGH (38)
Name:Rudransh
Age: 4 years 9 months old
Sex:Male
Born of non consanguineous marriage and birth order is 1
Address: Tirwa kannauj
Religion:Hindu
Informant :Father (reliable)
Date of admission :11/09/2024
Date of examination:16/09/2024
 Chief complaints
1. Fever ×20days
2. Fatigue ×14 days
 HISTORY OF PRESENTING ILLNESSS
According to the father the child was asymptomatic 20 days ago
When he had developed fever which was acute in onset and was
of low grade but has persisted without Significant spikes,with the
temperature ranging between 100°F and 101°F. The fever
doesn't seem to worsen at any particular time of day.

There are no associated symptoms like chills ,cough, runny nose

,sweating or vomiting. There are no noticeable rashes. Also he
does not have any urinary symptoms such as burning sensation
during urination ,increased frequency or difficulty passing
urine .Temperature returns to normal after taking medications like
Paracetamol which he has been using to reduce the fever.
Rudransh’s father says Rudransh has been increasingly
lethargic preferring to lie down rather than play.His father also
noted that the child has been unusually tired and ha lost
interest in food over the past few weeks

He also noticed his son becoming more pale and irritable.he

also mentioned that his son tends to eat small amount of food
particularly avoiding vegetables.

The child also have recurrent oral ulcers

 NEGATIVE HISTORY
● No H/O yellowish discloration of skin or Eyes.
● No H/O blood in vomit , blood in stools.
● No H/O skin bleeds, gum bleeds.
● No H/O passing worm in stool.
● No H/O any drug intake ,radiation ,blood transfusion.
● No H/Oweight loss night sweats , bone pain .
● No H/O consumption of inedible nonnutritive substances.
● No H/O rashes on the body , itching .
● No H/O cold, cough.
● No H/O increased frequency of micturition,excessive crying during
micturition.
 PAST HISTORY
● episode of diarrhoea and weight loss was seen after 3 to 4 days of birth
● past hospitalisation after birth
● No h/o similar complaints in the past
● No h/o any medication intake
● No h/o any blood transfusions
● No h/o any chronic disease
● No h/o tuberculosis, asthma, epilepsy
 FAMILY HISTORY
● Members:6 (grandparents ,parents and 3 kids)
● No abortions or stilbirths.
● Child has two more siblings of age 3 years and 1 year. Acc tonthe father
both of them also have low body weight.
● Both parents are of average build.
 ANTENATAL HISTORY
The child is of first order born out of non consengenous marriage having 2
more siblings with a gap of 1 year between the first and second child

The mother was a registered case and history is as follows:

1st trimester
● No h/o rash ,fever
● Folic acid taken
● No other drug intake or radiation Exposure
● No alcohol/tobacco/substance abuse
2nd trimester

● 2 doses of tetanus Toxoid taken 1 month apart

● Iron, folic acid and calcium Taken
● No abnormality noted on scan
● No h/o headache, swelling of feet , documented hypertension.
● No h/o polyuria polydyipsia and OGTT was done and was normal
3rd trimester

Appreciated fetal movement Well .

No h/o maternal fever, diarrhoea , UTI.
 BIRTH HISTORY

● Place :At home

● Mode: Normal vaginal delivery
● Period of Gestation :32 month
● Baby cried immediately after birth.
 POST NATAL HISTORY

● Birth weight :2.8kg

● Pre term (32 weeks)
● Child cried immediately after birth
● Breast feeding was not done after birth
● No respiratory difficulty, jaundice, cyanosis or seizures
 DEVELOPMENTAL HISTORY
Time Gross Fine Social Language

3 months Neck/head control Hold object with all Recognizes. Mother Cooing
fingers and palm and smile

6 months Sits with support Undexterous reach Recognizes stranger Ba, pa , ma

transfer objects

9 months Stand with support Pincer grasp Waves bye bye Mama , papa

12 months Stand without Spoon feed with Comes when called 1-2 words
support spills

1 ½ years Running Without spills 10 words

2 years Stair climb with both Wear shoes Goes toilet on own 2-3 word
legs Sentences

3 years Upstairs with single Dress /undress Knows gender/

steps Name

4 years Downstairs with Draws plus sign Color discrimination Sentences (6-7
 IMMUNIZATION HISTORY

Child was immunized upto date according to National

Immunization schedule.
 DIET HISTORY
Breastfeeding was not done in the child. The child was started on
cow’s milk after birth without dilution 400 ml per day . Within first
week the Child developed diarrhoeal Episodes for Which he was
taken to the hospital. And after the treatment mother Restarted
cow’s milk in 1:2 dilution.
After 9 months of age complimentary feeding was started. The
child was fed mashed rice with dal twice a day.
TIME FOOD ITEMS AMOUNT CALORIES(kcal) PROTEIN(g)

8:00 AM MILK 100 ML 36 1.6

SUGAR 20 g 20 0

CHAPATI 1 small (20g) 70 2.5

TOTAL 126 4.1

10 am Chana (roasted) 20g 70 4

Milk 100 ml 36 1.6

TOTAL 116 5.6

12:00pm Rice ½ cup (55g cooked) 55 1

Dal ½cup (100g) 70 4

Seasonal vegetable ½cup (100g) 80 2

TOTAL 113 5
TIME FOOD ITEMS AMOUNT CALORIE(kcal) PROTEIN(g)

4:00pm Roasted peanuts 20g 113 5

TOTAL 113 5

6 pm Parle-G biscuit 2 piece 60 1

Milk 100ml 36 1.6

TOTAL 96 2.6

9:00pm Chapati 1 small (20g) 70 2.5

Dal ½cup (100g) 70 4

TOTAL 140 6.5

Daily total
Calories - 740kcal
Protein-30.2 g
 SOCIOECONOMIC STATUS
House : 2 room kacha house with a kitchen, separate bathroom
and toilet.

Father occupation : farmer (8000 per month ) education till middle

School
Mother occupation :housewife , no schooling
Per capita income per month - 8000/6 =1333
Modified BG prasad - class 4
General Examination
• Child is conscious , recognising father, not interested in surroundings, irritable

• VITALS

• Temperature:- febrile

• PR :- 92 bpm

• BP : -106/ 76 mmHg

• Spo2 :- 99%

• Hydration:- Irritable, dry oral mucosa and tongue, skin pinch test goes back
slowly : some dehydration
Head to Toe Examination
• Pallor:- Moderate level

• Icterus :- Not present

• Cyanosis:- Not present

• Clubbing:- Not present

• Koilonychia :- 2nd stage

• Lymphadenopathy:- Not present

• Edema :- not present

• Head :- normal in size and shape

• Hair :- lustreless , thin , brittle

• Face :- normal ( hollow cheek appearance) , no frontal bossing

• Oral cavity:- oral mucosa dry ,ulcers present, fissures present at the
angle of the mouth and lips(angular cheilitis present) , no cleft lip and
palate, no bleeding at gum

• Eyes :- no discharge

• Nose and nasal cavity:- normal

• Neck: - no rashes around neck

• Chest :- Ribes are prominent, no Rachitic rosary and No Harission’s
sulcus observed

• Umbilicus :- central inverted

• Abdomen:- scaphoid abdomen

• Genitalia:- normal

• Groin :- visual wasting present,

• Back:- prominent scapula

• Extremity:- knuckle’s not hyper pigmented, scaphoid abdomen

Anthropometric
Parameters Observed Expected Inference
Weight 10kg <12kg <-3 SD
Height 94 cm <95cm <-3SD
Weight for age 10 kg <12.1 kg <-3SD
Height for age 94 cm < 94.7 <-3SD
Weight for height 10kg <11kg <-3SD
MUAC for age 12cm <12.8cm <-3SD
HC for age 46.2 <48cm <-3SD

Inference:
Severely underweight
Stunting
Wasting
Systemic examination
Gastrointestinal examinations
• Inspection:-

• Shape: scaphoid abdomen

• Movement: all quadrants move equally

• Umbilicus : central and inverted

• No skin scar or incision

• Superficial dilated veins not present

• No swelling

• No hematoma
• Palpation:-

• Liver :- liver not palpable

• Liver span is 6cm

• Spleen not palpable

• No mass and tenderness

• No hepatology or spleenomegaly

• Percussion:-
• Tympanitic note present

• No shifting of dullness

• Auscultation:-
• Normal bowel sound

• No bruit
Respiratory examination

• Inspection
• Size and shape:- Circular in shape and bilateral symmetrical

• Movement: normal rhythm and adominothoracic

• Trachea centrally placed

• Respiratory rate:- 22 breaths/ minute

• Palpitations

• Size : 50cm

• Equal movement of chest both sides

• Trachea placed midline

• Apex beat normal

• Tactile vocal fremitus : equal both sides

• Percussion

• Normal Resonating sound both sides

• Auscultation

• Air entry: equal on both side

• Breathing type: vascular sound

• Vocal Resonance: bilateral equal

Cvs examination

• Inspection
• Shape: symmetrical
• Apical impulse : not visible
• No scar and visible veins
• Palpitations
• Apex beat : normal and confined to one ics felt in < 1/3 systole
• No thrill
• Percussion
• normal dull note at precordial area
• auscultation

• Clear S1 and S2 sound

• no murmur
Investigation

• CBC with PBC with Reticulocyte count

• CRP

• KFT

• LFT

• CXR PA view

• PBS with retic count

• Montoux test
• GA for truenat

• Ironic profile

• Stool examination
Diagnosis
• 1.) Severe Acute Malnutrition

• Criteria

• Weight for height <- 3 SD

• 2.) Anemia
Stage Hb(g/dl)
• Criteria for 2- 6 years :
Mild 10-11.5
• Patient Hb(g/ dl) :5.7 g/dl Moderate 7-10
• MCV:- 54.3 ft Severe <7

• MCH :- 14.2 pg

• Patient diagnosed with Severe Anemic of Microcytic hypochromic

• Diagnosis: child is severe acute malnourished with severe nutritional anemia with multiple micronutrients and
vitamin deficiency with some dehydration
Community diagnosis

• Rudransh is 57 month old boy primarily driven by the family’s low socioeconomic
status,resulting in poor access to nutrition,healthcare and education on appropriate feeding
practices
• The combination of severe acute malnourished with severe micronutrient anemia ,micronutrient
and vitamin deficiency after presenting with fever from 20 days and Lethargic condition it reflects
border challenges of poverty, malnutrition and restricted access to essential health services
• MANAGEMENT OF SEVERE ACUTE
MALNUTRITION

• Types of SAM-

• Uncomplicated Sam

• Complicated Sam

• Medical Complications -Severe

anaemia,pneumonia,diarrhea,dehydration, lack of
appetite,TB,HIV, heart disease etc.
 Uncomplicat complicate
c

ed sam d samlicated
Samc

Appetite Good Poor

Edema Absent Present

Medical
Absent Present
Compilations

Intervention Home management Hospital management

HOME MANAGEMENT OF SAM
• food
Nutrition therapy-initially catchup diets; later home
Goal to Provide 175kcal/kg/day
6-8 times a day
Diets-RUTF(Ready to use therapeutic food)
Nutritive value :543kcal+15gprotein per 100gm
• Other treatment-oral amoxicillin for 5 days
Albendazole : if <2y give 200mg
>2y give 400mg
Vit A dosage: <6months-50000IU
6-12 months-1lakh IU
>12months-2lakh IU
Age appropriate vaccines
• Supervision
initially and support-home visit by health workers,
Daily ,later twice a week
• Sensory stimulation-play,physical activity’interaction
HOSPITAL MANAGEMENT OF SAM
2 Phases: Stabilisation phase
Rehabilitation phase
(1)HYPOGYCEMIA- blood glucose<54mg/dl
Treatment-if asymptomatic :give 50ml of 10%glucose orally
Feed with starter F-75 every 2 hourly
with-If symptomatic:give 10%dextrose IV 5ml/kg stat followed
Glucose infusion.
Feed with stater diet every 2 hourly.

(2)HYPOTHERMIA-rectal temp <35.5° celsius,axillary

temp<35°C
Treatment-clothe
also cover the child with warm clothes, head should
With scarf.
Provide heat using overheated warmer ,skin contact
Avoid rapid rewarming
(3)DEHYDRATION-
Treatment-give reduced osmolarity ORS with potassium
Supplements for rehydration
Use of F-75 formula on alternate hours along with
reduced
Osmolarity ORS
Be alert signs of over hydration
Prevention-give
stool ORS at 5-10ml/kg after each watery
Continues breastfeeding
(4)ELECTROLYTES-Hypokalemia
Hypomagnesemia
Sodium levels increased
Treatment-Potassium at 3-4mEq/kg/day for at least 2 weeks.
On day 1,give 4mEq/ml magnesium sulphate
Thereafter,give extra magnesium(.8-1.2mEq/kg daily)
Excessive Sodium avoided.
Decrease salt in diet.
(5)INFECTION-usual signs of infection such fever are often
Absent.
M/c bacteria gram-negative
Treatment -Ampicillin 50mg/kg/dose 6 hourly for 2 days
followed by Amoxicillin 15mg/kg 8 hourly for 5 days
Gentamicin 7.5mg/kg
If no improvement in 48 hrs -give 3rd generation
cephalosporins
(6)MICRONUTRIENT-multivitamin supplements
recommended
Dose-twice RDA value
Vit A, if age>1year give 2 lakh IU
age 6-12 months give 1 lakh IU
Age 0-5 months give 50000 IU
Folic acid, 1mg/day
Zinc 2mg/kg/day
Iron 3mg/kg/day,once
phase of child starts gaining weight; after
Stabilisation.
(7)INITIATE FEEDING-upto 1 week.
F-75 diet used: 75kcal+0.9gram protien/100g
Start with F-75 starter feeds every 2 hourly
Goal:80kcal/kg/day + 0.8-1g/kg/day protein.

(8)CATCH UP GROWTH-after 1 week

Once appetite return in 2-3days,encorage higher intake.
Increase volume and decrease frequency of feeds.
Make gradual transition from F-75 to F-100.
F-100: 100kcal+2.9g protien/100g
Goal: 175kcal/kg/d + 4-6g/kg/d protein.
(9)SENSORY
15-30min/daySTIMULATION-play therapy at least
Cheerful,physical activity.

(10)PREPARE FOR FOLLOW UP-

● failure to respond is indicated by:
Failure to regain appetite by day 4.
Failure to start losing edema by day 4.
Presence of edema on day 10.
Failure to gain at least 5g/kg/day by 10 day
TREATMENT COMPLETION
• No edema for at least 2 weeks
• Weight for height: -2SD/MAC reaches 12.5cm
• 400mg
Deworming to be done prior tp discharge -Albendazole
single dose
 Treatment of anemia in this Patient
ORAL IRON MEDICATIONS

Ferrous sulfate (20%elemental iron )

3-6 mg/kg/day elemental iron
● Reticulocyte count Increases after 72-96hr

After correction of anemia Oral iron should be continued for 4-6

months to replenish iron stores
PARENTRAL IRON MEDICATIONS

Indications
● Intolerance to oral iron
● Malabsorption states
● Ongoing blood loss at a rate greater than oral replacement

Injection ferric carboxymaltose : 15 mg/kg over 15-20 minute (upto 1000mg)

BLOOD TRANSFUSION

In very severe anemia with congestive cardiac failure, packed red

celltraznsfusion must be given very slowly (2-3ml /kg)
FOR VITAMIN B12 DEFICIENCY

Vit B12 - 1000 mcg i.m daily for first 2 weeks

1000 mcg weekly untill haematocrit normalizes

FOR FOLIC ACID DEFICIENCY

Oral folic acid 1-5mg daily 3-4weeks

THANK
YOU