EXAMINATION.pptx .

medical examination

1. Peads presentation

2. Demographics NAME: JP AGE 1YR9MONTHS SEX: MALE RELIGION: CHRISTIAN (PENTECOST) INFORMANT: MOTHER RESIDENCE: KANYAMA DOA: 16/01/25 DOH: 16/01/25

3. PRESENTING COMPLAINT INABILITY TO WALK OR STAND 1/7

4. HISTORY OF PRESENTING COMPLAINT -Patient was in his usual state of health until 2/52 ago when the mother noticed he developed diarrhea. Hx of diarrhea: Consistency: Watery Color: Yellow, non bloody Frequency: 5-7times /day The mother noticed the child wouldn’t feed as usual. However there was no abdominal distension, visible wasting and the diarrhea was not associated with meal related triggers. 4 days prior to admission, the child developed a wet cough that was accompanied by vomiting (non projectile) following an episode of persistent cough. there was body hotness and difficulty in breathing. The mother noted swelling of the face, arms and feet. however there was no specific triggers for cough.

5. On Thursday 16/1/25 The mother noticed that the child became irritable, stopped sitting, standing, and walking but could seat with support. she then brought him to KGH where the child was admitted .

6. Review of systems CNS: Loss of consciousness- Seizures - CVS Dyspnea+, orthopenia -, bilateral pedal edema GUT Urine color: normal (whitish yellow) Dysuria -

7. MSS and Skin Changes No weight loss

8. Past medical history E °.A°.T°.H °.D S ° Child is not exposed No history of similar illness, surgery or hospital admissions

9. Drug hx Paracetamol , ORS at home and unknown medication at hospital. No known drug and food allergies

10. Birth history Prenatal: ANC 2 visit. Mother did not take haematinics due to vomiting during pregnancy Perinatal: MOD via SVD BW: 4.2kg Baby cried immediately after delivery No birth complications

11. Immunization History Up to date according to the mother however not confirmed from the immunization card

12. Nutrition history Exclusive breast feeding for 2 months, mixed feeding was introduced and weaned off at 1 year 6 months

13. Developmental Hx Seated at 5 months Teething 6 months Standing at 10 month Normal developmental milestones

14. Family hx D °.E°.A°.T°.H°.S ° no similar illness Social Economic Hx Currently staying at grandmothers place in kanyama . 2 roomed house occupied by 11 people (4 adults and 7children). Born in a family of 6 (last born child). Both parents are not employed. Father drinks but doesn't smoke, the mother neither smokes nor drinks .

15. Summary JP 1-year-9-month-old male child from kanyama presented to kgh with hx of inability to walk or stand 1/7 prior to admission jp had a 2-week history of watery diarrhea (5–7 times/day) associated with poor feeding and a 4-day history of wet cough, fever, shortness of breath and vomiting. the child later developed inability to stand or walk, prompting the mother to seek medical attention. however, there was no weight loss, or meal-related triggers. no altered consciousness, seizures. of note, there is no clear record of immunisation, ANC, and has poor nutritional hx

16. IMPRESSION Malnutrition secondary to Chronic diarrhoea disease pneumonia DIFFERENTIAL DDX Severe malaria Acute kidney injury Acute flaccid paralysis Enteric fever

17. EXAMINATION

18. Vital signs Temperature 37.2 Respiratory rate 30cb/m Pulse rate 122 b/m Rbs 4mmol/l Spo2 96-97%

19. GENERAL EXAMINATION LERTHAGIC NO RESPIRATORY DISTRESS, NO BREATHING AID GENERALISED ODEMA NO FINGER CLUBBING POOR CAPILLARY REFIL>3SEC NO PERIPHERAL CYANOSIS PULSE REGULAR, FAINT

20. HEAD TO NECK GOOD HAIR DISTRUBUTION, BLACK IN COLOR PUFFY FACE EYES: PALE CONJUCTIVA NO OBVIOUS JAUNDICE SEEN EARS: NO EAR DISCHARGE NOSE: NO NASAL POLYPS, NASAL DISCHARGE SEEN NO NASAL FLAIRING

21. MOUTH: NO ORAL THRUSH,HAS MILK TEETH NECK: NO CERVICAL LYMPHADENOPATHY NECK IS MOVING WITH NO RESISTANCE JUGULAR VEIN NOT DISTENDED AXILLARY AND INGUINAL LYMPHNODES NOT ASSESSED DUE TO IRRITABILLITY

22. CHEST EXAMINATION UNDER RESPIRATORY ON INSPECTION ; NO SCARS SEEN PALPATION : SYMETRICAL CHEST EXPANSION, CENTRALISED TRACHEA PERCUSION NOT DONE AUSCUTATION : ANTERIOR SIDE, CREPITATION ON THE MIDDLE ZONE ON RIGHT SIDE LEFT LOWER SIDE WITH MILD CREPTATIONS POSTERIOR SIDE NORMAL

23. CARDIOVASCULAR SYSTEM INSPECTION; NO PERICODIAL SCARS PALPATION NOT DONE AUSCATATION; REGULAR HEART SOUNDS NO ADDED HEART SOUND APEX BEAT ON 5 TH INTERCOASTAL SPACE MIDCLAVICULAR LINE

24. ABDOMEN ON INSPECTION ; NO SCARS SEEN SLIGHTLY DISTENDED ABDOMEN ABDOMEN MOVING WITH RESPIRATION ON PALPATION; RIDGIT ABDOMEN, NO OBVIOUS MASSPALPATED DUE TO RIDGIDITY AUSCULTATION NOT DONE DUE TO IRRITABILITY

25. LOWER EXTRIMITIES BILATERAL PEDAL PITTING ODEMA +3 WITH SOME HYPERPIGMENTATION

26. DEHYDRATION ASSESSMENT IRRITABLE EYES TEARS WHEN CRYING, NOT SUNKEN DRINKS POORLY SKIN TUGOR GOES BACK SLOW (1-2 S)

27. ARTHROPOMETRIC MUAC 14CM LENGTH 78.0 CM WT 9.7 KG ODEMA +3 Z SCORE WEIGHT FOR AGE -SD LENGTH FOR AGE -2SD WEIGHT FOR LENGTH (BETWEEN -1SD AND MEDIAN )

28. D iagnosis Malnutrition secondary to Chronic diarrhoea disease with some dehydration Pneumonia Complicated malaria DIFFERENTIAL DDX Acute Kidney Injury Acute Flaccid Paralysis Enteric Fever Nephrotic Syndome Cardiac Failure

29. INVESTIGATION RDT MPS

30. FBC FBC

31. MANAGEMENT MANAGEMENT OF MALARIA Investigations Definitive investigation RDT, MPS Supportive FBC Initiail management ABCD Definitive mgt : based on severity, resistance and type of species ARTESUNATE 3mg/kg IM/IV at 0 hour , 12hour , 24hour Supportive management Paracetamol 7.5/kg 8 hourly po for 3/7 Treatment for pneumonia X PEN 50000iu/kg qid iv/ im 5 days

32. Treatment for malnutrition Ruft test positive Management of Hypothemia Hypoglcemia Dehydration Electrolytes Infection Micronutrient Initiation of feeding Catch up feeding Sensory stimulation Follow ups

33. Thank you Go home