Identification She was exclusively breast fed 6 times per day on average by

switching of breasts after emptying one up to now. The

This is MG a 10 months old female infant who is from chelia,
parents tried starting complementary feeding with shiro but
west shoa, Oromia. She was admitted to SPHMMC, DPCH,
was difficult as the baby was crying. She has been exposed to
right ward bed number 04 on Ginbot 19/2013 EC after being
sunlight starting from 1 month, everyday for 30 minutes
referred from Gedio Hospital and 3 days stay in the PEOPD
starting from 2 o’clock, with clothes on and ointments
here in SPHMMC.
applied. (Lack of knowledge)
Her mother is W/ro FJ a 32 years old farmer who is married to
She is not able crawl, pull to stand, pincer grasp, feed herself
the father of this child. She is not educated and is orthodox
with bottle. But she can sit unsupported.
faith follower.
She is the sixth child and has 4 brothers aged 16, 13, 10 and 7
Her father is Ato GK a 38 years old farmer who is not
years old and 1 sister who is 4 years old. All are relatively
educated and is orthodox faith follower.
healthy without any known medical illness. There is no
The historians were the parents with a translator but it seems familial history of cardiac disease, HTN, stroke, diabetes,
reliable. The date of clerking was on Ginbot 22/2013 E.C in cancer, abnormal bleeding, allergy and asthma or epilepsy.
the morning.
She lives with her parents and 5 siblings in a 3-room house
Previous admission with separate kitchen and 2 functional windows. There is a
To be mentioned in the HPI separate latrine which is 7m away from the main house. They
use spring water for drinking and cleaning purposes. They
Chief complaint dispose their wastes by burying them outside of the house.
Cough of 3 days duration They use firewood and charcoal for cooking purpose. There
are dogs and cattle living in separate house.
History of presenting Illness
Otherwise,
This is a 10 months old female infant who was relatively
healthy 15 days ago at which time she started to develop  She has no hx of chocking and gagging before the onset of
cough. The cough was non-whooping, non-barking type and the cough; (foreign body aspiration)
was persistent. It interrupted her feeding and her sleep.  she has no hx of wheezing and family hx of asthma
Associated with the cough, she had fast breathing that begun  she has no hx of body swelling (CHF, SAM)
insidiously, excessive sweating while breast feeding, low  she has no hx of hoarseness of voice during cough and
grade intermittent fever, irritability, loss of appetite, crying(tracheobronchitis)
unquantified weight loss, non-projectile, non-blood tingled,  she has no hx of ear discharge (otitis media)
non-foul smelling, and non-bilious vomiting of milk with 2-3  she has no hx of night sweats, contact with chronic cougher
episodes per day for 2 days and also watery, non- bloody or known TB patient.
diarrhea which is yellowish to brown in color with 2-3  She has no hx of contact with someone with URT
episodes per day for 2 days. symptoms. (bronchiolitis)
 she has no hx of change in urine output or sunken
For the above complaints she was taken to Gedio Hospital.
eyeballs(dehydration)
She stayed there for 5 days and was given intranasal oxygen
 she has no history of medication use prior to developing
and unspecified IV medication twice per day. Then, she was
the diarrhea (C. difficle)
referred to SPHMMC after the parents were told that it is
 she has no history of LOC and ABM
beyond their capacity. Currently she is on intranasal oxygen,
azithromycin syrup, vancomycin hydrochloride 1g IV and
ceftazidime 1g IV. Birth history
She is born to a 32 years old Para VI (all alive by SVD) mother Immunization history
who had no ANC visit. Then after 9 months of amenorrhea
she delivered vaginally with spontaneous ROM at home. She
Nutritional History
doesn’t know the birth weight but she heared the baby cry Developmental History
immediately after birth. In general, there were no
Past medical and surgical history
complications before, during or after pregnancy.
There are no past major medical illnesses, surgeries or
She was vaccinated only once at 6 weeks at home by health known allergies.
extension workers. She received oral drop and upper arm and
mid-thigh injections. The parents had an appointment at the Family and social History
9th month but due to the current complaint they didn’t
vaccinate their child.
 Review of Systems
General: No history of night sweats, malaise, itch/rash Interpretation (using WHO chart)
Head: No history of Head injury or dizziness. WFA: between 0 and -2 Z score(normal)
Eyes: No history of Redness, discharge, yellowish discoloration, LFA: between 0 and -2 Z score(normal)
vision defects
HCFA: between 0 and -2 z score(normal)
Ear: No history of Discharge, bleeding, aches, hearing loss,
ringing ears WFL: between 0 and -1 z score(normal)

Nose: No history of Bleeding, discharge, sneezing, stuffy nose, H.E.E.N.T

Head: Normal shape and size. No gross deformities, swellings,
Mouth/throat: No history of Ulcerations, gum bleeding, dental
scars or tenderness. No area of tenderness or scalp infections.
carries, difficulty of swallowing, hoarseness
Dark non pluckable hair.
Respiratory: mentioned in HPI
Ears: small and low set ears, no discharge, no tenderness over
Cardiovascular: mentioned in HPI but No history of difficulty of the mastoid process
breathing in supine position, fainting, palpitations, body
Eyes: up slanted palpebral fissures, epicanthal folds present,
swelling, cyanosis
pink conjunctiva, non-icteric sclera, no discharge, no
Gastrointestinal: mentioned in HPI but no history of periorbital edema, no nystagmus or strabismus.
constipation, yellowish discoloration of the skin
Nose: Small nose, depressed nasal bridge, no discharge.
Genitourinary: No history of frequency and urgency central septum, no tenderness over the maxillary and frontal
sinuses
Locomotors: No history of Joint swelling or deformities,
trauma, limited movement, pain, weakness, Mouth and Throat: open mouth, protruded tongue, No
cyanosis or ulceration of lip. No cleft lip. No papillary atrophy,
Integumentary: No history of Rash, lump, itching, dry skin, hair thrush, or dryness. Moist buccal mucosa. No gum hypertrophy.
and nail changes No hyperemia or swelling of the tonsils.
Central Nervous System: No history of Abnormal body
Lymphoglandular system
movement, tremor, numbness, paralysis.
Lymph nodes are not palpable over the occipital, post
Physical Examination auricular, pre auricular, submandibular, submental, cervical,
supraclavicular, axillary, epitrochlear, or inguinal regions.
General Appearance
The patient is well looking. She is awake. She is not in Respiratory system:
respiratory distress but is on intranasal oxygen. She has grossly Inspection: No nasal flaring, peripheral or central cyanosis,
dysmorphic features and looks undernourished. clubbing, mass or deformities. No scar. No subcostal and
intercostal, but there are suprasternal retractions. no audible
Vital Signs wheeze or stridor. Ribs are not prominent.
Pulse rate: 150 bpm measured from Right radial artery,
regular, full in volume… Tachycardic(80–120) Palpation: central trachea, no superficial mass or tenderness,
symmetric chest expansion. tactile fremitus not done because
Respiratory rate: 60 breaths per min, regular…tachypnea of age.
Blood Pressure: not measured due to unavailability of Percussion: there is resonant percussion tone over the chest
appropriate BP cuff wall. (Diaphragmatic excursion is not done.)
Temperature: 36.8 oC, axillary in the morning…Normal Auscultation: Vesicular breath sounds heard over the lung
SaPO2: 92% with IN oxygen fields. Equal and good air entry on both sides. Diffuse
wheezing. But no stridor, crepitation, rhonchi, or pleural
Anthropometry friction rub.

Weight: 7.2 kg Cardiovascular system:

General: There is slight palmar pallor but no cyanosis or
Height: 66 cms
clubbing.
HC: 43 cms

MUAC: 11 cms……severe malnutrition

Arteries: Pulse is palpable over, carotid, brachial, radial, CNS:
popliteal, anterior tibialis, and dorsalis pedis bilaterally. No General: she is awake and irritable.
radio femoral delay.
Cranial nerves:
Veins: No distended neck, chest, abdomen, and leg veins. JVP
is not done. CN I- not done

Precordium: CN II- intact Direct and indirect pupillary light reflexes. Visually
acuity and fundoscopy not done.
Inspection: The precordium is quiet. There is no bulging or
abnormality in shape. Apical beat is not visible. CN III, IV &VI - the eyes can move in all directions, no
nystagmus and strabismus. No ptosis.
Palpation: No tenderness. The PMI is palpable in the left 5th
interspace, slightly lateral to the mid-clavicular line. It is CN V- effective and strong sucking of breast.
localized and tapping. There are no palpable heart sounds. no
CN VII- Face is symmetrical at rest and upon voluntary
thrills or heaves.
movements like smiling, nasolabial folds are present bilaterally
Auscultation: S1 and S2 are well heard. They are not muffled and no mouth deviation.
or accentuated. no added sounds were appreciated.
CN VIII- responds to mobile ringing tones.
Abdomen: CN IX & X- coordinated swallowing of breast milk
Inspection: The abdomen is flat. It is symmetric and moves
with respiration. There is 2*3 umbilical defect with positive CN XI- symmetric shoulders with no shoulder drop
cough sign. There are no scars. No visible veins, peristalsis or
CN XII- coordinating sucking, swallowing and tongue thrusting
pulsations.
during cry.
Auscultation: No bruit over the abdominal aorta, renal
Motor: hypotonic limbs. Bilaterally comparable muscle bulk,
arteries, or iliac arteries. Normoactive bowel sounds (12/min)
no spontaneous fasciculation.
Percussion: Tympanic percussion tone over the abdomen. No
Reflexes
Signs of fluid collection (shifting dullness and fluid thrill).
Superficial: the plantar reflexes are intact
Palpation:
Deep tendon reflexes: Not done
Superficial – No tenderness, guarding, rigidity or superficial
mass Primitive reflexes: not assessed

Deep – No deep tenderness, organ enlargement Sensory: Light touch sensation is intact.

Genitourinary system: Coordination: not done

No suprapubic mass and tenderness. Normal appearing female
external genitalia.

Integumentary system:
Skin: erythematous patchy lesion on the face, slight palmar
pallor, No jaundice, cyanosis, hyper or hypopigmentation. The
skin is dry and warm.

Hair: Normal distribution, dark color, soft texture

Nails: Pink, no cyanosis, no clubbing and capillary refill is 2

sec(normal)

Musculoskeletal system:
Look: Comparable but thin muscle bulk, no extra digit or
webbing of digit. No spine deformities.

Feel: There is no tenderness, warmth, crepitations, or swelling

over the joints

Move: There is no asymmetry and limitation in movement of

limbs.
  Infertility
Clinical Features of Down Syndrome
 Obesity
Central Nervous System
 Hyperthyroidism
 Hypotonia*
Musculoskeletal
 Developmental delay
 Poor Moro reflex*  Joint hyperflexibility*
 Short neck, redundant skin*
Craniofacial
 Short metacarpals and phalanges
 Brachycephaly with flat occiput  Short 5th digit with clinodactyly*
 Flat face*  Single transverse palmar creases*
 Upward slanted palpebral fissures*  Wide gap between 1st and 2nd toes
 Epicanthal folds  Pelvic dysplasia*
 Speckled irises (Brushfield spots)  Short sternum
 Three fontanels  Two sternal manubrium ossification centers
 Delayed fontanel closure
Cutaneous
 Frontal sinus and midfacial hypoplasia
 Mild microcephaly  Cutis marmorata
 Short, hard palate  Hyperkeratosis
 Small nose, flat nasal bridge  Seborrhea
 Protruding tongue, open mouth  Xerosis
 Small dysplastic ears*  Perigenital folliculitis

Respiratory * Hall's criteria to aid in diagnosis.

 Obstructed sleep apnea

 Frequent infections (sinusitis, nasopharyngitis,
pneumonia)

Cardiovascular

 Endocardial Cushing defects

 Ventricular septal defect
 Atrial septal defect
 Patent ductus arteriosus
 Aberrant subclavian artery
 Pulmonary hypertension

Hematologic

 Transient myeloproliferative syndrome

 Acute lymphocytic leukemia
 Acute myelogenous leukemia

Gastrointestinal

 Duodenal atresia
 Annular pancreas
 Tracheoesophageal fistula
 Hirschsprung disease
 Imperforate anus
 Neonatal cholestasis
 Celiac disease
 Delayed tooth eruption

Endocrine

 Congenital or acquired hypothyroidism

 Diabetes mellitus