3. Identification:
Name: Sabrina Abdo age: 4yrs sex: female
Card number:208547
Address:East wallega Chawaka
Date of admission: 22/3/2016
Source of data
Mother’s name: Yadeni Dikensa age: 32 yrs
occupation: house wife
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4. Chief complain
Body swelling of 2 weeks duration
History of Present Illness
This is a 4 years old female child who was
relatively well until two weeks. At which time she
started to develop body swelling. Her mother
noticed the swelling first appeared on the Lower
extremity then progressively involved to her other
body parts and it is not painful.
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5. She has no history of hospital admission but
visiting local private clinic with diagnosed
malnutrition, no medication was given and Referred
to this hospital for further management.
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6. Together with the swelling, she has history of
vomiting of ingested matter 2 to 3 times per day that
is aggravating by feedings and she has 3 times per
day of watery diarrhea.
she has history of failure to gain weight for 3
months and loss of appetite.
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7. Otherwise no history of constipation or abdominal
pain. She has history of skin rash on both lower
extremity No history of shortness of breath and
chest pain. She has history of cough and no history
of contact with chronic cougher or a person
diagnosed with TB. No history of night sweats,
previous treatment with TB.
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8. Past medical and surgical history
No family history of chronic disease like bronchial
asthma, diabetes, hypertension.
No history of child hood illnesses such as measles
and pertussis.
No history of operation, fracture and burn.
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9. Family history
She lives with her mother and father in a family
size of seven.
she is the third child for the family. she has three
brothers and one sisters.
Her family is illiterate and farmer.
The family gets around four thousand Ethiopian
birr per months.
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10. Immunization history
According to her mother said she was vaccinated up
to nine months.
The specific details like type of vaccine and time of
injection is not known well.
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11. Nutritional history
She was on exclusive breast feeding up to 4 months.
she started complimentary feeding like cow milk, Aja at
4 months. She was breastfeed up to 2 years.
Before she got sick she was on family diet which she
eats 3 times per day.
Her breakfast, lunch and dinner was mostly injera with
shiro.
Their injera was usually made from maize.she feeds
with her brothers and sisters.
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12. Developmental history
She was no developmental delay and
developmental regration.
Currently she can jump by both feet, play with
many children and goes to toilet alone, knows her
sex and age.
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13. Birth history
Duration of pregnancy was 9 and 1/2 months.
Delivery was at health center by spontaneous vaginal
deliver after 8 hours of labor.
The baby was cried after birth and her weight was 3 kg.
The baby has no history of difficulty of sucking after
birth
There were no any known complications.
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14. Review of systems:
General: no changes in sleeping pattern, no night sweats or
malaise.
H.E.E.N.T
Head: no headache, no head injury
Ears: no impaired hearing, no discharge.
Eyes: no discharge, redness or blurred vision.
Nose: no discharge, runny nose or sneezing
Throat: No sore throat, hoarseness of voice, no dental caries,
no bleeding gums, no lesions.
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15. Respiratory: No chest pain, breathlessness or
wheezing.
Cardiovascular: No fainting, palpitations, cyanosis.
Gastrointestinal: No constipation, no abdominal
pain
Genitourinary: No dysuria, frequency, urgency.
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16. Integumentary: rashes, no lumps, no hair or nail
changes.
Musculo skeletal system: no history of pain or
swelling of the joints.
Central nervous system: No seizures, speech defect
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17. Physical examination:
General appearance:
The child is conscious and looks stable.
Vital signs: At admission
PR:122 beats/min RR: 26 breaths/min
Temprature:36.1⁰c Oxygen saturation 94% off of
oxygen.
28/3/2016
PR:128 beats/min RR: 28 breaths/min
Temprature:37.1⁰c Oxygen saturation 92% off of
oxygen.
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18. Anthropometry
Weight = 15 kg Height=113cm MUAC=13 cm
WFA: between -2 and -3 z-score(moderate under
weight)
HFA: between -1 and -2 z-score (normal)
WFH:less than -3 z-score (wasting)
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19. H.E.E.N.T
Head: Normal shape which is round of head. Normal hair
color, distribution and texture of hair over the scalp.
Ears: Normal position, no discharge, no tenderness over the
mastoid.
Eyes: pink conjunctiva, no discharge.
Nose: no discharge, no nasal deformity and patent nose.
Throat: No cyanosis of the lip, tongue. Dry mucosa.
No dental caries or mucosal ulceration. No swelling of
tonsils.
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20. Lymphoglandular system
No enlarged lymph nodes.
Respiratory system:
Inspection: symmetrical chest movement, no chest
deformities or visible scars.
Palpation: No superficial mass or tenderness over the
chest wall.
Percussion: resonant sounds.
Auscultation: Bilateral and equal air entry. Vesicular
breath sound anteriorly and posterior chest. No
wheezing, stridor.
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21. Cardiovascular system
S1 well heard on apex of anterior chest
S2 well heard on pulmonary and Aortic.
No murmur, gallop sound.
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22. Gastrointestinal system
Inspection: There is flat Abdomen.
There are no distended veins.
The abdomen moves with respiration.
There is no scar.
Auscultation: normoactive bowel sounds heared at RLQ
Palpation: there is no superficial mass or tenderness.
No palpable organo megally
Percussion: there is Tanpanic,No dullness.
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23. Genitourinary system
There is normal female external genitalia
No vaginal discharge.
Integumentary system
Skin: She has skin rash on both lower extremity
which is grade III and some palmar pallor.
Hair: normal hair color, texture and distribution over
the scalp.
Nails: no clubbing.
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24. Musculo skeletal system
No joint deformity.
No decrease of range of motion.
She has bilateral pitting edema grade +++ on her
legs.
Central nervous system
Conscious and Alert.
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26. Medical Diagnosis
Complicated SAM (Edematous with wasting )+
AGE with no Dehydration + Hospital Acquired
pneumonia + Dermatitis grade (+++)
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27. Treatment
F-75 165ml per feed every two hour
Ampicillin 50 mg/kg IV QID
Gentamycin 5mg/kg IV daily
ReSoMal 75 ml /loss
Zink 20mg po/day for 10 days
10% Zink oxide ointment apply.
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31. Diagnosis:
Imbalanced nutrition less than body requirements
related to inadequate intake as manifested by child
family verbalized.
Impaired skin integrity related to disease process as
evidenced by visible skin lesion on her lower
extremities.
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32. Diagnosis:
Risk for infection related to weakened immune
system.
Fluid volume deficit related to vomiting and
diarrhea as evidenced by weak pulse rate and dry
mouth.
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33. Planning:
Goal :The child will be get adequate nutrition.
Outcome: the child will be get adequate nutrition by
feeding F-75 after 1 week.
Goal: The child will be improved from skin integrity
Outcome: The child will be improved from skin
integrity after applying 10% Zink oxide ointment within
1 week duration.
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34. Planning:
Goal :The child will be free from infection
Outcome: the child will be free from infection by
administering antibiotics after 1 week.
Goal : The child will be rehydrated.
Outcome: The child will be rehydrated by giving
F-75 and ReSoMal within 1day.
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35. Implementation:
Nutritional support was Provided based on
malnutrion guide line start F- 75.
Nutritional support was Provided and 10% Zink
oxide skin ointment was applied.
Antibiotics was Administered as prescribed, to
manage infection.
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36. Adequate F-75 feedings was provided and given
ReSoMal solution.
The patient's intake and output, weight, and vital
signs regularly was Monitored.
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37. Evaluation:
The child get Adequate nutrition.
The child improved from impaired skin integrity.
The child gets Antibiotics.
The child Rehydrated and the pulse rate is strong.
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