Severe Acute Malnutrition

Clinical case presentation

By S.Shravan Kashyap
rd
3 year MBBS
MVJ MC & RH
Patient particulars
Name xyz
Age 9 months
Sex female
Born of non consanguineous marraige and is birth order 1
Address: Hoskote
Religion: Hindu
Informant mother reliable
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Date of admission 10 may 2020 7am
th
Date of examination 10 may 2020 9 am
Chief Complaints
● Inability to gain weight since 2 months
● Diarrhoea since 3 days
● Irritability since 1 day
History of presenting illness
The child was apparently normal 3 days back when child started
vomiting , the vomitus contained breast milk following which the child
had loose stools which was sudden in onset ,clear with 2-3 episodes on
the first day less in quantity and increased to 6-7 episodes on the third
day and was about 50 ml in total and the child tends to cry when
passing stools.
There is no H/O of blood or mucous in stools, or foul smelling stools
The child was initially playfull on the first day but has become more
irritable and cries more frequently since two days, the child also
refuses any complementary feed and only takes breast milk
intermittently.
The child is also thirsty and the frequency of urination also has
decreased to only one time yesterday.
.
There is no H/O
● Fever
● Distention of abdomen
● Convulsions
● Passage of worms in stools
● any food allergy

Child is not bottle fed and has not been given any food from
outside
Past History
● Similar episode of diarrhoea one month back that was self
limiting
● No history of vaccine preventable diseases in the past
● Child has decreased appetite since the last episode of
diarrhoea on month back

Treatment history
● The mother did not give any treatment and brought the child to
hospital on worsening of the symptoms
Family history
No significant family history
No history of recent travel
No similar complaints of diarrhoea in the family
No history of TB in any of the family members
Birth history
Pregnancy
Booked at MVJ MC & RH
Pregnancy confirmed after 2 months of ammenorhea
Total of 6 antenatal visits
Total weight gained 12.5 kg
Period of gestation: 38 weeks
Antenatal History

ST
1 Trimester
Folic acid Taken
Dating scan done
No H/O of UTI, fever, rash, lymphadenopathy
exposure to radiation or drugs
No H/O of hypothyroidism
 ND
2 Trimester
Quickening at 20 weeks
2 doses of TT taken 1 month apart
Iron, folate and calcium taken
Anomaly scan done, OGTT done, NT scan done all are normal
No H/O headache, blurring of vision, pedal edema
No H/O polyuria, polydipsia
No H/O fever with rash, lymphadenopathy
No H/O bleeding PV
 RD
3 Trimester
Appreciated fetal movements well
Growth scan done
No H/O preeclampsia, headache, blurring of vision, pedal edema
No H/O bleeding PV, leaking PV, foul smelling discharge
No H/O maternal infections
No H/O PROM
Labour
Time and date : 30 August 2019 ,5pm
Full term normal vaginal delivery

Postnatal history
Birth Weight : 2.8 Kg
Baby cried immediately after birth
No NICU admission and no post natal complications
Breast feeding was initiated ½ an hour after delivery
Given adequately on demand during day and night
DOMAINS MILESTONE AGE OF EXPECTED AGE
ATTAINMENT
GROSS MOTOR Neck Holding 3 month 3 month

Rollover 6 month 6 month

Sit with support 6 month 6 month

Sitting without 8 month 8 month

support & crawling
FINE MOTOR Hand regard 3 month 3 month

Bidextrous grasp 4 month 4 month

Unidextrous grasp 8 month 8 month

& transfer of
SOCIAL Social
objectssmile 2 month 2 month

Mother regard 3 month 3 month

Mirror play 6 month 6 month

LANGUAGE Vocalise 2 month 2 month
Visual fixation 4 weeks 4 weeks
Cooing 3 month 3 month

Monosyllable 6 month 6 month

Immunisation
● At birth BCG, OPV, Hep B1
● 6 weeks DTwP1, Hep B2, Hib1, PCV1
● 10 weeks DTwP2, Hib2
● 14 weeks DTwP3, Hib3, PCV3
● 6 months OPV1, Hep B3
 Nutrition
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● Exclusively breast fed for the till 7 month, there was no difficulty in
breastfeeding
● Complimentary feeding was intiated at the 8 th month with 1-2 breast
feeds per day
● No history of allergy to any food .
● Based on the 24 hour recall method
● Morning : 1 idly and two to three teaspoon sambar = 150kcal + 1 gm
protein
● Afternoon : 2 chapathi medium size and ¼ katori dal= 160 kcal + 6.25gm
protein
● Breast feeding given only once at night and morning 100ml = 130kcal + 2.2
gm of protein
● Total : 440 kcal + 9.47gm of protein
Socio economic status
● Lives in a pucca house
● Belongs to class 4 socioeconomic status ( modified BG Prasad
classification)
● Source of water is borewell
● There is no open defecation around the house
Summary
● 9 month old girl of birth order one ,who was born of non
consanguineous marriage via normal full term normal vaginal
delivery was brought to the OPD with history of clear watery
diarrhoea withrdincreasing episodes since 3 days maximum of 6
episodes on 3 day with increased irritability , thirst and
decreased appetite since two days and not gaining weight since
2 months started on complementary feed of 440kcal and
9.47gm of protein per day and breast fed twice a day which is
inadequate for a child of 9month
● With this I consider that the child is suffering from acute
gastroenteritis with some dehydration and malnutrition
Examination
● Child is lying on the mother lap and crying intermittently,
● Child was conscious but also irritable , but is active
Vitals
● Temperature : afebrile 95F
● Airway- clear
● Respiratory rate- 45 cycles per minute , predominantly
abdomino-thoracic , pattern and depth normal , no usage of
accessory muscles of respiration
● sPO2 : 98%
● Pulse – 140 bpm normal in character ,regular in rhythm , low
volume pulse with no radioradial or radiofemoral delay.
● Blood pressure-60/50 mm hg lower side of normal
● Capillary refilling time 2sec

There is no pallor , icterus , cyanosis, clubbing , edema and

lymphadenopathy,
 ANTHROPOMETRY

Actual Expected Inference

Weight 6.5 kg 8.2 kg < -3 S.D
length 69 cm 70.1 cm < - 2 S.D
Weight for length 6.5 kg 8 kg < -3 S.D
th
Head 43.5 cm 44cm 50 centile
circumference
Chest 40cm 41cm
th
50 centile
circumference
Mid arm 11cm 13.5cm < -3 S.D
circumference

Based on the anthropometrical data and the WHO classification the child has
severe acute malnutrition
● Head to toe examination
Head: normal in size and shape, sunken anterior fontanelle,
Hair: easily plucable.
Eyebrows: normal ,
Face:, wrinkled appearance of face
Eyes: Sunken appearance of eyes, no signs of vit A deficiency
Ears: normal
Nose: normal
Oral cavity: dry , no cleft lip or palate, tongue is dry, no dentition, no signs of bcomplex
deficiency.
Neck: prominence of muscles of the neck
Chest: movement of the chest is seen, rib markings are prominent as subcutaneous fat
is lost
Umbilicus: normal
Abdomen: no distension
Genitalia: normal
Back: prominence of scapula , decreased subcutaneous fat over
the buttocks
Extremity: normal arms and legs show muscle wasting,
Skin: dry, loss of subcutaneous fat, skin pinch test 2.5 seconds
Feet: normal , no edema
Orifices: normal
Gastro intestinal system
Inspection
Shape of abdomen : normal
All quadrants move equally with respiration
Umbilicus central
No sinuses/scasrs/dilated veins
No visible peristalsis
Undue prominence of both the anterior superior and posterior superior iliac
spines
Skin is dry and shiny
Hernial orifices normal
Palpation
Baby cries on pressing the periumbilical region, no organomegally, no free fluid
Percussion normal
Bowel sounds normal
Systemic examination
● CNS
GCS 15
Higher mental functions
Conscious, irritable, responds to oral command
Cranial nerve examination
Cranial nerve Examination Right left
optic Recognises mother Present Present

Puppilary reflexes Red reflex present Red reflex present

Occulomotor nerve Able to follow objects Present Present
in all directions of gaze

Light reflex direct & Present present

Trigeminal nerve indirect
Corneal reflex present present
Facial nerve Eamination normal normal
Vestibulococchlear Responds to sound present normal
nerve

Motor system Upper limb Lower limb

right left right left

bulk Wasting of muscles seen symetrically Wasting of muscles seen symetrically

Tone hypotonia hypotonia hypotonia hypotonia

inspection normal normal normal normal

palpation normal normal normal normal

Resistance to Present Present present present

passive movement
Power
Upper limb 3+ 3+
Lower limb 3+ 3+
neck Able to lift head
trunk Able to turn around in
bed

Reflexes
Superficial reflex
Plantar response extensor
Deep tendon reflex
Biceps reflex normal
Supinator reflex normal
Triceps reflex normal
Knee jerk reflex normal
Ankle jerk reflex normal
Developmental assessment
No primitive reflexes seen , no abnormal movements

Sensory system
Pain- responded by crying
Other sensations could not be elicited
Respiratory system
Inspection
Shape normal
Undue prominence of ribs
Symetrical movement of both sides
Palpation : normal
Auscultation
Normal vesicular breath sounds heard
No added adventitial sounds
CVS
Inspection
JVP not elevated
Palpation
Apex beat felt
No parasternal heave
Auscultation
S1 S2 normal no added sounds
● Diagnosis
Acute gastroenteritis with some dehydration and severe acute
malnutrition