PSIL PRESENTATION

HISTORY

 12 months old boy resident of Thatta brought to

district hospital with the complaints of:

 Loose watery stools for 8 days

 Increased irritability and poor oral intake for 2
days
 The patient was well until 5 months of age. At 5
months his mother became pregnant again. His
mother had started to wean him from the breast
at 3 months, as her milk supply was reduced.
 From 4 months he was fed formula milk from a
bottle with a rubber teat. He was given solid food
from four months of age, mostly rice with daal
(lentil soup).
 Since the age of 5 months he had six episodes of
diarrhoea. Each episode lasted for 5-6 days,
which was treated locally from a medical shop.
 During each episode of diarrhoea he was given
reduced amounts of fluid and feeds because his
mother thought this would reduce the severity of
his diarrhoea.

 On this last occasion he was taken to the

hospital, as he became irritable and was not
drinking or eating well.
NUTRITIONAL HISTORY
 The boy was started on formula feed at 4 months
of age.
 The milk was diluted (one scoop of milk per
whole bottle of water). His mother would wash
his bottles and teats in tap water, and rarely
would boil the bottles.
 He was given weaning food at six months of age,
mainly contained rice with dal and only
occasional vegetables. He would get meat
occasionally, but not for the past 2 months.
 He usually received two meals and two bottles of
milk each day.He always had to share his plate of
food with his other siblings.
FAMILY AND SOCIAL HISTORY
 The boy lives with his parents in a small cottage.
 He has three older sisters and two older brothers.
They have a small plot of land on which they
grow crops, but which is not sufficient to feed
their family.
 Father works as a farmer and his mother as a
housemaid where they can earn some more
money for food and beverages.
 Because they are so busy, the older siblings
mostly take care of him.
 No history of any TB contact or HIV case in the
family.
ON EXAMINATION
 The patient is visibly wasted, pale, irritable having
skin folds over his arms, buttocks and thighs and
visible rib outlines.
 Vital signs:
 temperature: <35.0 0 C, pulse: 130/min, RR: 50/min
 Weight: 6 kg and Length: 69cm, MUAC 10.5cm

 Ears-Nose-Throat: dry mucus membranes

 Eyes: sunken, no tears and dry and pale conjunctiva
 Palms: severe palmar pallor
 Skin: decreased skin turgor, no skin changes, rash or
edema observed
 Chest: bilateral air entry was normal, no added
sounds
 Cardiovascular: both heart sounds were heard
and there was no murmur
 Abdomen: soft, bowel sound was audible; no
organomegaly
 Neurology: irritable, sick looking; no neck
stiffness and no other focal signs
CASE SUMMARY
 12-month-old boy, youngest of family of 6. Several episodes
of gastroenteritis since he was five months of age.
 For the last 8 days he has been having frequent loose
watery stools.
 History is significant for early weaning, diluted dirty
formula, poorly nutritious food and repeated infections.
 Large family size and poor socioeconomic status.
 On examination pale, irritable, and ill-looking. He is
visibly wasted, having skin folds over his arms, buttocks
and thighs. He has visible rib outlines, hypothermia,
sunken eyes with no tears and dry conjunctiva and
decreased skin turgor.
DIFFERENTIAL DIAGNOSIS
 Primary severe malnutrition
 Secondary severe malnutrition in the course of: -
-Tuberculosis
-HIV
-Pneumonia
-Measles
-Malabsorption syndrome
-Micronutrient deficiency (Vitamin A, zinc)
LEARNING OBJECTIVES
 Differential diagnoses
 How will you investigate to make final diagnosis?

 Main diagnosis

 Secondary diagnoses

 List possible causes of the illness-identify the

risk factors.
 How will you treat? Enlist all the 10 steps of
treatment according to WHO recommendations.
WHAT INVESTIGATIONS WOULD YOU LIKE
TO DO TO MAKE YOUR DIAGNOSIS?

 Blood glucose - 2.4 mmol/L (3-6.5mmol/L)

 Haemoglobin - 70 g/l (105-135)

 Chest x-ray - Normal

 Stool microscopy - shows trophozoites of giardia

FINAL DIAGNOSIS
 Primary Severe Malnutrition
 Anaemia

 Giardiasis
TREATMENT
 Treatment includes 10 steps in 2 phases:
 Initial stabilization and
 Rehabilitation
10 STEPS OF MANAGEMENT OF A
MALNOURISHED CHILD AS PER WHO
GUIDELINES

 Step 1 : Manage Hypoglycemia

 Step 2 : Manage Hypothermia

 Step 3 : Manage Dehydration

 Step 4 : Manage Electrolytes

 Step 5 Infection

 Step 6 Micronutrients

 Step 7 Initiate feeding

 Step 8 Catch-up growth

 Step 9 Sensory stimulation

 Step 10 Prepare for discharge and follow-up

PROGRESS ON OUR CASE
 The patient was managed as per above guidelines.
 He was discharged before full recovery on parents
request.
 His parents were told to feed him at least 5 times per
day.
 They had to give him high-energy snacks between
meals (e.g. milk, banana, bread, biscuits).
 His parents were told to assist and to encourage him
to complete each meal, to add electrolytes and
micronutrient supplements to each feed and to monitor
his intake as well.
 His mother was encouraged to breastfeed him as
often as he wants.
 Follow-up was arranged. He still needs
continuing care as an outpatient to complete
rehabilitation and prevent relapse.