TUTORIAL

PRESENTATION
MODERATOR: DR.NGOMA
DEMOGRAPHICS

NAME: Y.C
SEX: FEMALE
AGE: 5 YEARS OLD
DATE OF BIRTH: 25TH JUNE 2019
RESIDENCE: CHELSTONE
TRIBE: BEMBA
LANGUAGE OF INTERVIEW: ENGLISH
INFORMAT: MOTHER
DATE OF ADMISSION: 17TH MAY 2025 in A07
DATE OF CLERKING: 20TH MAY, 2025 (3 Days post Admission)
REFERRAL: SELF-REFERRAL
CHIEF COMPLAINT

 Cough for the past 3 weeks (3/52)

HISTORY OF PRESENTING
COMPLAINT
This is a known Neuronal migration disorder (Lissencephaly) and Epileptic patient who
presented with a cough for the past 3 weeks. The cough is said to occur at any time of the day,
not related to food intake, productive in nature with yellowish-white thick sputum, non-foul
smelling, worsened when it is cold and the mother tried to treat the cough by giving the patient
Amoxicillin, ginger and steaming but could not subsidize . The mother noted that the patient
expresses discomfort when coughing as the patient does not speak of which she suspected that
the patient was having chest pains. This was associated with difficulties breathing but no
history of coughing up blood, choking, wheezing, nasal congesting, runny nose, shortness of
breath when lying flat, waking up to catch a breath and swelling of the legs.
The mother reports that the patient has had loss of appetite for a long time of which she was
taken to the hospital where they gave her multivit which could help stimulate the appetite but
once she stops giving the multivit, the patient would lose appetite. The mother reports that the
patient has lost weight from 14.5 kgs in August last year to 9.5 kgs in February this year and
currently on 10.5 kgs. There is a history of constipation since infancy associated with abdominal
distention and abdominal pain as patient could hold her abdomen and cry but no history of
diarrhea and vomiting. The constipation is treated with enema and There is no history of fever,
night sweats and decrease in urinary frequency.
At the time of clerking, no cough and difficulties in breathing were noted.
REVIEW OF SYSTEMS

1. Respiratory system, cardiovascular system and gastrointestinal

system as in History of presenting complaint.
2. Central Nervous System: H/O of convulsions precipitated by
pain and body weakness but No H/O of syncope and abnormal
movements.
3. Musculoskeletal: No H/O edema, joint swelling, rash and
jaundice.
4. Genitourinary system: No H/O of hematuria, poly or oliguria and
dysuria.
PAST MEDICAL AND SURGICAL
HISTORY
 The patient has a history of similar presentation multiple times.
 There has been several hospital admissions:
- First admission was when the patient was 5 months old in 2019 for seizures. Mother
would note jerking of the upper limbs only and staring gaze from the patient which
would last 1-2 minutes.
-She could convulse up to 30 times in a day
- Second Admission was in 2020 for seizures and a cough where CT-scan was done
which reviewed that the patients brain was smooth instead of having brain folds . A
diagnosis of Neuronal migration disorder (Lissenchephaly) and epilepsy was made
and the patient was put on antiepileptic drugs (Sodium valproate and
Levetiracetam) and the last seizure was in February this year. The patient was also
diagnosed with pneumonia.
- Third admission was last year where a patient presented with cough ,diarrhea with
loss of appetite and a diagnosis of pneumonia was made.
CONTINUATION

- Fourth admission was this year in February where the patient was
diagnosed with pneumonia
- Fifth admission is April this year and the patient presented with
cough and difficulties breathing. Diagnosed with Pneumonia.
- This is the 6th Admission at University teaching Hospital (UTH).
Continuation

 No H/O of Surgery
 No H/O of Diabetes Mellitus, Asthma, Tuberculosis, Hypertension
or Sickle cell Disease
 Patient is RVD-NR (Verbally)
DRUG HISTORY

 Past medication: sodium valproate and Levetiracetam for

Epilepsy and Amoxicillin for cough, multivitamin
 Current medication: cefotaxime, F-75, Folic acid, Levetiracetam
and sodium valproate
 Herbal medication: Ginger
 No Known Allergies
Birth History
 Antenatal
- More than 3 antenatal visits
- H/O of UTI at 5 months which was treated, H/O pregnancy induced
hypertension, no fever with rash and no other medical complication in
pregnancy.
- All ultrasound scans reviewed no abnormalities
- All medications required during pregnancy were taken (folic acid, Fansidar,
vitamin c, antitetanus injection)
 Natal
- Born at term via C/S due to pre-eclampsia
continuation

- with 3 kg birth weight

- Cried at birth and passed meconium after birth. Was breastfed
same day and discharged after 3 days.
- No complications in neonatal period (no jaundice and other
complications or illness).
IMMUNIZATION HISTORY

 All vaccines given as per national schedule (under 5 card not

seen)
 BCG scar seen
NUTRITIONAL HISTORY

 Breastfed up to 1 year 5 months

 Exclusively breastfed for 5 months then weaned with delight
porridge
 At 6 months, The mother started giving her porridge with
groundnuts and patient would finish the food.
 Dietary history;
-Breakfast: porridge with groundnuts
-Lunch: Nshima with any available relish (smashed for her to easily
swallow)
-Supper: blended fruits
 Patient is currently on F-75
DEVELOPMENTAL HISTORY

 Head control at 2-3 months

 Sitting with support at 2 years
 Producing sound at 5 years
 All other developmental milestones not attained
FAMILY HISTORY

 No similar presentation in the family

 Last born in the family of three. The other siblings are well.
 H/O of Diabetes (Father), H/O of hypertension (Mother) with no
H/O of Epilepsy, Asthma and TB or known TB contact
 Mother is RVD-NR
SOCIO-ECONOMICAL HISTORY

 Mother and Father are on separation

 Father is a business man and Mother is a Secondary School
teacher
 Live in a 2 bedroomed house with 4 occupants
 No one smokes in the house
 They use a flushable toilet
 Source of water is Tap water but they drink mineral water
SUMMARY

Presenting Y,C Female aged 5 years RVD-NR, A known

Lissencephaly and epileptic patient who presented with a cough for
3 weeks associated with dyspnea, chest pain, anorexia and weight
loss. a history of constipation, abdominal distension, abdominal pain
and global developmental delay but no history of orthopnea, PND,
edema, diarrhea, vomiting, fever and night sweats.
IMPRESSION

Recurrent Pneumonia with Severe acute malnutrition (with wasting),

functional constipation and global developmental delay in a known
Lissencephaly and epileptic patient.
R/O
1. Bacterial pneumonia
2. Aspiration pneumonia
3. Pulmonary Tuberculosis
4. Bronchiectasis
GENERAL EXAMINATION
I examined a female child who was lying supine in bed with a cannula in situ on the left hand and nasogastric
tube in situ. The patient was conscious, no obvious signs of respiratory distress and obvious muscle wasting.
Hand
- Had palmar pallor, No cyanosis, no koilonychia and no finger clubbing with Capillary refill time <3 seconds
(normal)
- Radial pulse was palpable and full volume, non bounding with Radial-Radial synchronicity.
- No epitrochlear and axillary lymphadenopathy.
Neck
-No lymphadenopathy
Head
- Hair normal color and distribution
- Afebrile
- Tearing of the eyes
- Had conjunctiva pallor, no scleral jaundice and no Bitot spots
- Oral cavity: moist ,no glossitis, no angular stomatitis, no beefy tongue and no oral thrust
Lower limbs
-No bipedal pitting edema
VITAL SIGNS

 O2 Saturation: 95% in room air (normal)

 Pulse: 98 beats/minute (normal)
 Respiratory rate: 24 breaths/minute (normal)
 Temperature: 36.3 (normal)
ANTHROPOMETRIC
MEASUREMENTS
 Weight: 10.5 kgs
 Height: 9.6 cm
 BMI: 11.4 kg/m2(BMI for age below the 3rd percentile and <-3 z-
score (indicating severe wasting)
 Weight for height <-3 z-score (severe acute malnutrition)
 Height for Age between -2 and -3 z-score (indicating moderate
stunting)
RESPIRATORY SYSTEM
 On Inspection
- No tracheal tugging
- Visible ribs, no scars, no deformities and moving with respiration
 On palpation
- Trachea is centrally located
- Equal chest expansion bilaterally
 On percussion
- Resonant percussion notes in all lung fields
 On auscultation
- Vesicular breath sounds with equal air entry bilaterally
CENTRAL NERVOUS SYSTEM

1. Cranial nerves
 Cranial nerve II intact (patient was able to follow objects)
 Cranial nerve III, IV and VI intact (moving in all planes)
 CN VII: Face symmetrical
 CN VIII: cochlear component is intact
2. Motor system
 Patients fists were clenched in both limbs
 Scissoring posture was noted
 Increased tone in all 4 limbs
 Primitive Reflexes: rooting reflex was present, sucking reflex was
present
CARDIOVASCULAR SYSTEM

 On inspection
- No distended neck veins
- Normoactive precordium
 On palpation
- Apex beat palpable in 4th intercostal space midclavicular line
- No parasternal heaves and no thrills
 On Auscultation
- Normal S1S2 heard with no added sounds
PER ABDOMINAL
EXAMINATION
 On inspection
- The abdomen was moving with respiration, abdomen not
distended with no distended veins and the umbilicus was
inverted.
 On palpation
-No tenderness elicited, no masses and no organomegally
 On Auscultation
- 3 bowel sounds were heard in 1 minute
MUSCULOSKELETAL

 No bilateral pitting edema

 No skin rashes
SUMMARY

I examined a female child lying supine in bed who was alert , no

obvious signs of respiratory distress with pallor, weight for height of
less than -3 z- score, height for age of between -2 and -3 z-score,
BMI for age indicating severe wasting, hypertonicity in all limbs,
primitive reflexes, reduced bowel sounds with no other abnormal
findings.
IMPRESSION

Resolving Pneumonia with Severe acute malnutrition (with wasting) and

moderate chronic malnutrition, global developmental delay, Anemia and
functional constipation in a known Lissencephaly and epileptic patient.
R/O
1. Bacterial pneumonia
2. Aspiration pneumonia
3. Pulmonary Tuberculosis
4. Bronchiectasis
5. Iron deficiency anemia
6. Anemia of chronic disease
7. Megaloblastic anemia
INVESTIGATIONS
 Laboratory
 FBC/DC
 ESR/CRP
 Random Blood Sugar
 Electrolytes
 Renal function test (Creatinine)
 Blood culture
 Stool for Gene Xpert
 Arterial blood gases
 Imaging
 Chest X-ray
INVESTIGATIONS DONE
Continuation
DIAGNOSIS AFTER
INVESTIGATIONS DONE.
Resolving Bacterial Pneumonia with Severe acute malnutrition (with
wasting) and moderate chronic malnutrition, global developmental
delay, Iron deficiency Anemia and functional constipation in a
known Lissencephaly and epileptic patient.
R/O
1. Pulmonary Tuberculosis
continuation

 Random Blood Sugar: 8.1 mmol/L

MANAGEMENT

 Principles of Management
 Admit the patient
 Manage complications of SAM as per A07 protocol
 Continue epilepsy management
 Manage functional constipation
 Refer to physiotherapy
Admitting patient

 Patient presented with:

• No appetite
• Medical complications (pneumonia).
Managing complications of
SAM
There is no:
 Hypoglycemia
 Hypothermia
 Dehydration
 Electrolyte imbalance
 Severe anemia
 Treatment of the Bacterial pneumonia
 Iv access
 Ampicillin 50 mg/kg IV QID
 Gentamicin 7.5 mg/kg IV OD
 Switch to oral amoxicillin 50-100 mg/kg TDS after two days when able to take orally.
 Treat the infection for 7 days
Continuation
 Start cautious feeding
 F-75 at 130 ml/kg/day every 3 hours day orally or via NG tube
 It may take up to 7 days or longer for a child to stabilize on F-75
 Adequately monitor amount of intake
 When appetite returns and no serious medical complication then we can
transition gradually to RUTF. Offer small amount of RUTF and at the same time
maintain the same amount of 3 hourly F-75.
 Then slowly increase RUTF
 Correct micronutrient deficiencies
 Multivitamin supplement
 Folic acid Day 1 5mg then 1mg/day
 Zinc 2 mg/kg/day
 Iron not in the first week of admission, only when a child starts gaining weight. In
the rehabilitation phase at 3 mg/kg/day
continuation
 Achieve catch-up growth
 RUFT or F-100 is used. Feeding is required to achieve very high
energy/ protein intake and rapid weight gain of >10g/kg/day
 Given at least 5-6 times/day
 Provide sensory stimulation and emotional support
 Provide loving care
 Cheerful environment
 Structured play therapy 15-30 minutes everyday
 Discharge the patient
 Appetite is restored
 All acute complications been corrected
 Advise to bring the child for regular follow-up checks
Continue Epilepsy management

 Levetiracetam (20-60 mg/kg/day 12 hourly)

 Sodium valproate (10-40 mg/kg/day)12 hourly
continuation

 Baclofen 1 mg QID for the hypertonicity

 Refer the patient to Physiotherapy.
END OF CASE PRESENTATION