this was a case presentation, in my pediatric department, of lyari general hospital. regarding a patient admitted in PCM ward.

1. case presentation
by
dr suresh kumar (house officer)
paeds department lyari general hospital

2. biodata
• my patient Iqra , 1 year old, 7.3 kg weight, resident of hub
chowki, admitted through opd on 1st september 2020, in
PCM ward of paeds department in lyari general hospital,
with CR # 11293.
PRESENTING COMPLAIN;
Loose motion for 03 month on and off and
swelling in upper and lower limbs for 03 weeks

3. HOPC
• According to mother of my patient , she was in usaual
state of health 03 month back, then she develops loose
motion 4 to 5 times for 1st 2 days then 6 to 7 times per
day. initially stool was greenish and bulky for 02 days then
becomes watery in consistancy and yellowish in colour,
completly fills diaper even leaks out from diaper, stools
having foul smelling, no blood staining. initialy she cried
during each loose motions, now a days she strains during
loose motion. not associated with abdominal distention,
vomiting, fever. she made multiple visits to locally general

4. physican, by which her motion stoped by medication (
medication not known by mother, but nt included ORS )
also complains of swelling, which is gradauly in onset starts
from feet bilaterally, progressive in nature upto knees, after 1
week it involved dorsum of hands and face specialy eyelids. it
is not associate with pain, tender no overlying skin colour
and temperature changes. while travelling swelling become
worse.

5. • PAST MEDICAL HISTORY: ( re admission case )
she was admitted with same complain of L/M and swelling 28 days
back for 09 days in paeds dept. LGH . she was diagnosed as severe
acute oedematous malnutration with persistant diarhea, for that she
was treated with PCM protocol, at time of discharge her loose motion
stoped and swelling improved.
. FEEDING HISTORY: breastfeeding started after 01 hour of dilievery,
exclusive breasfeeding for 03 months, then started weaning with water
drops and breastfeeding till 06 months, after that she started half slice
of bread in morning, half boiled potato in lunch, 3 to 4 spoon of khichdi
and half cup lassi in night.
CUURRENTLY: during illness, appetite decrease, eates only 1/4th
boiled potato, 2 to 3 spoon khichdi in night.

6. • BIRTH HISTORY:
• antenatal: she booked at 07months of pregnacy in LGH , had 5 to 6
visits , ultrasound was normal, multivitamin not taken, no HTN and
DM.
• natal: delivered at 09 months, by c-section in LGH due to prolong
labour, no maternal or fetal complication occured.
• postnatal: baby cried immedietly,no skin cynosed or yellow
discoloration, no birth trauma, breastfeed started after 01 hour of
dilievery, birth weight nt documented but according mother baby was
healthy by weight.
• VACCINANTION: vaccinated upto 14weeks , 09 months measels
vaccine missed.

7. • DEVELOPMENTAL HX:
• neck holding at 04 monts
• sit without support 06 months
• crawling 08 months
• now she can stand with support
• FAMILY HISTORY: cousin marriage ,only one child, mother father are
healthy.
• PERSONEL HISTORY:
• sleep distrubed, loss of appetite, weight loss ( non documented) use
boiled water.

8. • SOCIOECNOMIC STATUS : own home 2 rooms, 5 family members,
father only earning member, labour by profession with daily income of
300 to 400 rupees.
• RISK FACTORS:
• poor socioecnomic staus
• inapropriate weaning
• persistant diarhea
• GENERAL PHYSICAL EXAMINATION: child lying in nape of mother ,
irritable, looking sick and pale, with right hand canulated.
• VITALS: T = 99F, R/R = 30 breaths/min, H/R = 12O beats/min
• NON-VITALS: A++, J- , CL- , D- , bilateral pitting oedema in legs upto
knees and dorsum of hands.

9. • ANTHROPOMETRIC MEASUREMENTS:
• FOC=42.5cm MUAC=13.5cm
• LENGTH=75cm WEIGHT=7.3kg
• weight for height = -2SD
• HEAD TO TOE EXAMINATION:
• HEAD: Hairs are thin, sparse, but no colour changes, nt easly pluckable,
anterior fontenalle opened, nor depressed nor bulged. frontal bossing
present
• EYES: eyes are shinny, no bitot spot seen, palpeberal conjuctiva are pale
• MOUTH:angular cheilitis, stomatitis,
• HAND:both palm and palmer creases are pale, widening wrist
• CHEST: prominent ribcage , ricket rosery present

10. • ABDOMEN: protuberance of abdomen is present
• SKIN: flaky paint dermatosis present in inguinal region also
pigmented skin changes in lower limbs. bilateral pitting pedal
oedema upto shin.
• RELEVANT EXAMINTION OF ABDOMEN:
• inspection:
• palation:
• percusion:
• auscultation:
• CHEST: clear, with normal vesicular breathing
• CVS: S1 + S2 + 0

11. • PROVISIONAL DIAGNOSIS
• severe acute oedematous malnutrition
• LABS REPORT:
• CBC ON 03rd sept. 2020 . SERUM ELECTROLYTES
• on 3rd sept. 2020
hb 8.7
tlc 7,900
neutrophil 32%
lymphocytes 56%
eosinophil 06%
monocyte 06%
plateletes 1,85,000
mcv 66
rdwc 22.2%
MCH 21.7
sodium 136 meq/l
potasium 4.50 meq/l
chloride 110 meq/l
bicarbonate 11.5 meq

12. URINE DR ON 03 sept. 2020
pus cell 15-20
cast epithelial
STOOL DR ON 03 sept. 2020
mucus +
pus cell 2-4
entameoba histolytica +
02 sept. 2020
urea 20
creatinine .8

13. URINE C/S 06 SEPT 2020
>100,000 CFU/ml ECOLI
COLISTIN S
FOSFOMYCIN S
POLYMYXACIN S
AMIKACIN R
AMOXICILLIN R
AMPICILLIN R
CEFEXIME R
CEF-SUL R
CEFTRIAXONE R
CEFUROXIME R
CO-TRIAMAZOLE R
GENTAMICIN R
LEVOFLOXACIN R
MEROPENUM R
NITROFURANTOIN R
ABDOMINAL ULTRASOUND: ON 09 Sept. 2020
CONCLUSION: mild hepatmegaly with normal
shape, and homogenous echotexture of hepatic
parenchyma. gallblader, pancrease, spleen,
kidneys,urinary blader apprentaly normal, no
evidence of mass, ascites and abdominal
lymadenopathy was seen.

14. FINAL DIANGNOS:
PRIMARY SEVERE ACUTE OEDEMATOUS
MALNUTRITION
• TREATMENT;
• started with pcm protocol
• inj, cefotaxime 720 mg i/v od
• inj, amikacin 55mg i/v od
• syrup, vidaylin 1 tsf od
• cap, vit A 2 lac iu po stat
• tab folic aid 5md od, then 1mg
• inj, vit D3 2 lac i/m stat
• milk f75 60ml p/o 2 hrly
then after 2 days, 3 hrly 115ml, after
one 4hrly 120ml, after one switched
to f100, 120ml/4hrly.
. resomal; 50ml after every l/m
. zinc oxide paste 4 hrly
on 09 sept 2020;
.syp, fosfomycin 9ml 6hrly for 5
days
.syp, flagyl 1 tsf tds
hold f100 start resomal

15. thank you