PATIENT PARTICULARS

Name : Michael David.

Age : 4 years
Sex : male
Residence : Majengo
Informant : biological mother
Self referral from home
2 days in the ward
Chief complaints:
Fever for 1 weeks
Abdominal pain for 5days.
HISTORY PRESENTING ILLNESS (HPI)
The patient was apparent well till 1 week prior admission when her
mother noticed her child to have a fever which was gradual onset on and
off more marked at night. Mother give her child paracetamol which
subside the fever. Fever was associated with excessive sweating, general
body malaise, and dizziness. However mother dinied the history of loss
of consciousness, history of convulsion and the yellowish discolouration
of the skin.
On the fifth day the child experiencing abdominal pain which was
gradual onset colic in nature and generalized abdominal pain was not
radiated. Abdominal pain was accompanied with loss of appetite and
there was history of two episodes of vomiting which the vomitus was
about a quarter of tea cup, non-projectile, and yellowish in colour with
food content no foul smell. No history of diarrhea, constipation, no
history of pain full micturition, no history of urine stained with blood, no
foul smell in the urine.
REVIEW OF OTHER SYSTEM
RESPIRATORY SYESTEM
 No history of cough
 No history of difficulty in breathing
 No history of chest tightness
CARDIOVASCULAR SYSTEM
 No history of awareness of heartbeat
 No history of difficulty in breathing when lying flat
 No history of easy fatigability
 No history of lower limb swelling
Other system as per history presenting illness.
PAST MEDICAL HISTORY
This is the first admission of the child. No history of blood transfusion,
no history of surgery interversion, no history of any trauma also mother
report there is no history of drugs or food allergy.
ANTENATAL HISTORY
Mother booked clinic at the gestation age of 16 weeks and
attended 4 times till the delivery. No any complication during
pregnancy. First visit the mother was checked for malaria rapid
diagnostic test, vineraldisease research laboratory (VDRL)
PITC both test was negative. Also the patient was checked for blood
pressure and was normal in all visit and haemoglobin level estimation
and was normal. Was given tetanus toxoid vaccine as the first dose.
Second visit mother receives tetanus toxoid vaccine second dose,
intermittent preventive treatment SP, Iron sulphate, Follicacid,
mebendazole which is the same as the third visit and the fourth visit.
NATAL HISTORY
The baby was delivered at the full term with geststion age of 39 weeks
through spontaneous vaginal delivery and the baby was cried
immediately and was able to breast feed. No any complication during
delivery to the mother and baby.
POST NATAL HISTORY
The mother stayed at hospital within 24 hours after delivery,
Umbilicus was dropped after a week with no blood, no pus or any other
discharge, no any complication the baby encountered like yellowish
discoloration of the skin.
FAMILY AND SOCIAL HISTORY
Her mother is entrepreneur level of education is primary standard
seven she lives with her husband standard seven who is house maker.
Her child is the fourth born other siblings are ok. They lives in well and
good ventilated house and environmental sanitation is good also. No
history of any chronic illness running in the family including
hypertension, epilepsy, sickle cell disease, diabetes mellitus, and
HIV/AIDS. No history of alcohol or ciggarate smoking for both parents.
IMMUNIZATION HISTORY
 At birth receives BCG and oral polio virus OPV0
 After 6 weeks: OPV1, pentavalent1, PCV1, and rotarix vaccine
 After 10 weeks: OPV2, Pentavalent2, PCV2, and rotarix
 After 14 weeks: OPV3, Penta3, and PCV3.
 At 9th month was given measles vaccines and Vitamin A.
All vaccines given was good according to Expanded Program of
Immunization (EPI).
DIETARY HISTORY.
Exclusive breast feed for 6 months mostly 5 days per day and then when
the baby cried was breastfed. Followed by complimentary breast feeding
and the porridge which was mixed with maize, rice, ground nuts and
millet in which the baby was given four times per day one bowel per
each meal. Now the child eat with others social they eat ugali, rice,
vegetables and fruits mostly oranges and the meal is three times per day.
This is the good nutrional per day.
DEVELOPMENTAL MILESTONE
 Gross motor: control neck 3 months, sitting 4 months, crowing 6
months and standing alone 8 months.
 Fine motor: transfer object hand to hand 5 months, grasping 4
months
 Social behavior: smilling 2 months, say a single word da, ba 6
months, to say baba, mama 10 months.
This is the normal developmental mile stone.
SUMMARY 1.
Michael David 4 years old male from Majengo referred from
Chamwino health Centre with a complaints of fever for a week
gradual onset on and off associated with excessive sweating,
generally body malaise and dizziness. No history of loss of
consciousness, no history of convulsion. Also complaints abdominal
pain colic in nature gradual on set, associated with loss of appetite,
vomiting 2 episodes per day non projectile contained with food
particles yellowish in colour no foul smell. No history of diarrhea,
constipation, pain full micturition or urine stained with blood.
PHISICAL EXAMINATION
GENERAL EXAMINATION
 The patient was alert, oriented, ill looking and febrile.
 Normal hair distribution, normal texture block in colour.
 No ears, nose discharge
 Pale on conjunctiva
 Not jaundiced
 No central and peripheral cyanosis
 No angular stomatitis
 No lymphadenopathy
 No finger clubbing
 No lower limb oedema

VITAL SIGNS
 Temperature 37.80C
Respiration rate 28 breath per minute
Pulse rate 84 beats per minutes. Stable vitals except body
temperature.
ANTHROPOMETRIC MEASUREMENTS:
Length 112 cm
Weight 20 kg
MUAC 16 cm
OFC 46cm

SYSTEMIC EXAMINATION

RESPIRATORY SYSTEM
Inspection
 No traditional and surgical mark
 Chest wall contour are Normal with no deformities like Kyphosis,
Scoliosis, Pectusexcavatum, Pectuscarinatum.
 The patient has Signs of respiratory distress like, nasal flaring ,use
accessory muscles of respiration like sternocleidomastoid
muscles,
 Diaphragmatic paradox the diaphragm moves opposite of the
normal direction on
Inspiration,
 lower chest wall in drawing

Palpation
 No Palpable swelling or tenderness
 Trachea is centrally located
 unequal chest expansion
 Increased tactile vocal fremitus (TVF)

Percussion
 Hyper resonant percussion note
Auscultation
 Vescular sound heard

CARDIOVASCULAR SYSTEM
Inspection
 No peripheral cyanosis, no finger clubbing
 No surgical scar
 No lower limb edema

Palpation
 Apex beat located on 4thintercostal space along the left
midclavicular line
 No thrill

Auscultation
 Heart sounds S1 and S2 heard
 No mummers

PER ABDOMEN
Inspection
 The abdomen is flat, moving with respiration
 Inverted umbilicus
 No visible surgical, traditional mark.

Palpation
Superficial -Not tender on palpation
-No palpable mass

Deep -No hepatomegaly, there is spleenomegaly

- Both Kidney are not palpable.

A tympanic percussion note was heard on percussion,

Normal bowel sound heard on auscultation.
CENTRAL NERVOUS SYSTEM
 Conscious With Glass gow coma score of 15/15
 Patient is alert and Patient is oriented with people and place
 Speech of a patient is good

Cranial Nerves
 Olfactory - The patient can smell
 Optic – The patient can see
 Oculomotor, Trochlear, Abducen - The patient can move eyes on
both direction like to move eyes upward, downward, medially and
laterally.
 Trigeminal, Facial – Symmetrical face and the patient can blow
cheeks and able to show wrinkles,
 Vestibulocochlear – The patient can hear
 Glossopharyngeal, Vagus – Normal Gag reflex, Uvula centrally
located
 Accessory - The patient can moves his shoulder upward against
resistance, able to shrug shoulders.
 Hypoglossal – The patient can move tongue out and on both
direction

Motor
Muscle Bulkness—Normal on both extremities
Muscle Involuntary - No involuntary

Muscle Gait –
Muscle Tone – Normal tone on both extremities
Muscle Power – power of 5/5 on both extremities (normal)
Muscle Reflex – Normal reflex on both extremities
Muscle Sensation – Patient can sense by using both tooth pick and
cotton on both extremities.
SUMMARY 2

Michael David 4 years old male from Majengo, referred from Hombolo
health Centre with a complaints of fever for a week gradual onset on and
off associated with excessive sweating, generally body malaise and
dizziness. No history of loss of consciousness, no history of convulsion.
Also complaints abdominal pain colic in nature gradual on set,
associated with loss of appetite, vomiting 2 episodes per day non
projectile contained with food particles yellowish in colour no foul
smell. No history of diarrhea, constipation, painfull micturition or urine
stained with blood.
On examination febrile, ill looking, pale not jaundiced, no
lymphadenopathy, there is splenomegaly.

PROVISIONAL DIAGNOSIS

Severe malaria due to fever, generalized body malaise, dizziness.

DIFFERENTIAL DIAGNOSIS

Septicemia due to fever

LABORATORY INVESTIGATIONS
 Malaria rapid diagnostic test
 Blood smear for malaria parasites
 Full blood count
 Random blood glucose
 Blood grouping and cross matching.

MANAGEMENT;

 Artisunate 48 mg intravenous at 0, 12 and 24 hours.

 Paracetamol 250 mg PO 8 hourly for 3 days
 Ampicillin 1 g intravenous 12 hourly for 5 days
  Gentamycin 150 mg intravenous once per day for 5 days
MONITORING
Blood pressure, pulse rate, respiration rate and temperature,
FOLLOW UP
Check blood smear for malaria if negative shift from artisunate
toArtimetherLumefantrine (ALU) 2 tabs per oral at 0, at 8 then after
every 12 hours from the first dose for 3 days.

DISCUSSION
MALARIA.
Malaria refers to an acute and chronic protozoan infection caused
by a parasite plasmodium which infects Red Blood Cells (RBCs).
It is the number one cause of morbidity and mortality especially in
children below five years of age.

CLINICAL FEATURES OF MALARIA.

o Malaria is a most severe in children lacking antibodies and is
milder in children having survived initial attacks.
o The illness is characterized by nonspecific prodromeprior to the
onset of sudden high fever and chills.

UNCOMPLICATED MALARIA:
The child has the following;
 Fever ( temperature ≥ 37.50C ) or a history of fever
 Nausea and vomiting
 Diarrhea
 Poor appetite

LABORATORY INVESTIGATION:
 Malaria rapid diagnostic test
 Blood slide for malaria parasites
 Random blood glucose
MANAGEMENT OF UNCOMPLICATED MALARIA
  First line is Artemether (20 mg) – Lumefantrine (120 mg) ALU
plus Paracetamol 10 mg/kg – 15 mg/kg.

SEVERE MALARIA
The following are the presentation / clinical presentation of severe
malaria
 Fever
 Lethargic or unconscious
 Acidosis ( presenting with deep, labored breathing )
 Generalized weakness
 Jaundice
 Severe pallor
 Hepatosplenomegaly
 Shock
 Convulsion
 Vomiting everything
LABORATORY INVESTIGATION
 Blood slide for malaria parasites
 Haemoglobin level estimation, ( haemoglobin less than 5 g/dl )
 blood grouping and cross matching
 Random blood glucose ( blood glucose less than 2.5 mmol/litre
TREATMENT OF SEVERE MALARIA
 Check for hypoglycaemia and correct
 Treat convulsion with phenobarbital 10mg/kg to 20mg/kg IM
 Restore the circulating blood volume
 If the child is unconscious minimize the risk of aspiration
pneumonia by inserting nasogastric tube
 Treat severe anaemia
 Start treatment with effective antimalarial as follows

 Artisunate 2.4 mg/kg intravenously on admission at 0, 12,

and 24 hours for minimum for 3 days
  Paracetamol 10mg/kg to 15mg/kg 8 hourly for 3 days.

DIFFERENTIAL DIAGNOSIS
 Bacterial Meningitis
 Septicaemia

COMPLICATION
 Hypoglacaemia
 Anaemia
 Trauma
 Renal failure
 Liver failure
PREVENTION, CONTROL AND FOLLOW-UP
 Using mosquito treated net during bed time
 Vector control, indoor spraying.
 Eliminate mosquito breeding sites
 Children with severe malaria should be followed up after 4 weeks.
REFERENCE:
 Pocket book of hospital care for children world health
organization
MOHSW, WHO, UNICEF 2002 .IM.
 Management of child with serious infection or severe
malnutrition, Guidelines for care at first referral level.
 Dar es salaam, Tanzania Ministry of health and social welfare.
 PREMATURE CASE REPORT
DEMOGRAPHICS DATA
NAME : JEMIMA HAULE
AGE : 5 DAYS
SEX : FEMALE
RESIDENCE : KIKUYU
INFORMANT : BIOLOGICAL MOTHER
2 DAYS IN THE WARD
CHIEF COMPLAINTS
Un able to breast feed for 4 days.
HISTORY OF PRESENTING ILLNESS
The patient was born on 5th days by spontaneous vertex delivery
weight of 2.5 kg scored 5 at first seconds and also 7 at fifth minutes,
cried immediately after delivery but the baby was un able to breastfeed,
which was accompanied by fever, no history of convulsion, no history of
loss of consciousness, no history of diarrhea and no history of abdominal
distension.
REVIEW OF OTHER SYSTEM
RESPIRATORY SYSTEM
No history of cough
No history of difficult in breathing
Other system is as per history presenting illness.
FAMILY SOCIAL HISTORY
Mother is a student college by education level she lives with her
husband who is also a collegee. He is her first born. No history of
chronic illness in the family like hypertension, diabetes mellitus,
epilepsy, sickle cell disease and HIV/AIDS. They live a well and good
ventilated and good environmental sanitation. No history of cigarate
smoking or alcohol taking.
ANTENATAL HISTORY
Mother booked clinic at a gestation age of 20 weeks and attend 2
times until delivery in which at the first visit mother was screened for
malaria, VDRL, PITC and both results were negative. The mother was
given first dose of tetanus toxoid. And the blood pressure were 124/82
mmHg and Haemoglobin level were 12.4mmol/dl.
On the second visit mother was given a second dose of tetanus toxoid in
addition to mebendazole, iron sulphate supplement, folic acid
supplement and intemetent preventive care (SP). Also the blood pressure
and haemoglobin level were normal.
NATAL HISTORY
Mother deliver the baby at gestation age of 29 weeks through
spontaneous vertex delivery and was hospital delivery baby delayed to
cry for 15 seconds and was an able to breast feed. The having a
complication of peripheral cyanosis.
POST NATAL
The mother reported the baby having the un able to breast feed and
delayed cry.
IMMUNAZATION HISTORY
Child immunized one day after delivery BCG at right shoulder, has no
full immunized according to expanded program of immunization.
DIETARY HISTORY
She is still on Exclusive breastfeeding, mother reported having the
enough milk

PHYSICAL EXAMINATION:
GENERAL EXAMINATION.
Patient was alert and febrile
Normal hair colour, normal hair distribution, normal frontanelle, no ear,
nose, eyes discharge, normal mouth, no central cyanosis, normal neck,
normal ears, no any chest deformities, normal niples, abdomen not
distended, unsterile umbilicus, no blood in the umbilicus, peripheral
cyanosis, the testes was descended and the anus was well.
VITALS
Temperature 36.90C
Oxygen saturation 86%
Respiration rate 76 cycle per minutes
SYSTEMIC EXAMINATION
CARDIOVASCULAR SYSTEM
 Sound one and sound two was heard with no additional murmurs
RESPIRATORY SYSTEM
 No any chest deformities
 No any therapeutic mark
On auscultation
Normal vesicular sound was heard with no addition sound
SUMMARY
Jemima Haule a female of 5days from kikuyu noticed of having a un
able to breastfeed for 4days that was soon after delivery by
spontaneously vertex delivery and accompanied with fever with no
history of convulsion loss of consciousness and also no history of
diarrhea.
PROVISIONAL DIAGNOSIS
 Birth asphyxia secondary to prematurity
DIFFERENTIAL DIAGNOSIS
 Early onset of neonatal sepsis secondary to prematurity due to
the history of fever, un able to breast feed, failure to thrive.
 Mild hypoxic ischemic encephalopathy ( Thomson score 9 )

LABORATORY INVESTIGATION
 Full blood count
MANAGEMENT
 Oxygen therapy 1 litre
 Ampicillin 76 mg intravenous 8 hourly for 5 days
 Gentamycin 7.6 mg intravenous once per day for 5 days
 Chroramphenical eye ointment
 Vitamin K injection 0.5 mls stat.
 The baby should be kept warm
MONITORING
Close monitoring for oxygen saturation, temperature and respiration rate
of the baby
FOLLOW UP
Check the condition of the baby every half an hour to check the
prognosis of the baby.

DISCUSSION
BIRTH ASPHYIXIA
Birth asphyxia refers to the failure of the newborn to establish
spontaneously respiration (breathing) immediately after birth.
AETIOLOGY/ OR CAUSES OF BIRTH ASPHYXIA
The causes have been categories in to two classes as follows;
I) MATERNAL CAUSES
 Prolonged labour
 Obstracted labour
 Breech delivery when at term
 Antepartam haemorrhage
 Pregnancy induced hypertension ( severe pre eclampsia and
eclampsia )
 Gestational diabetes
 Smoking
II) PLACENTAL / FOETAL CAUSES
 Cord compression
 Cord prolapse
 Cord occlusion
 Pre maturity
 Maltiple births
CLINICAL PRESENTATION
 Lethargy
 Generalized hypotonia
 Absent or diminished moro and grasp reflex
 Apnoea
 Respiratory rate more than 60 breath per minutes or less than 30
breath per minutes
 Cyanosis
 Slow heart rate

ASSESSMENT AND MANAGEMENT OF BIRTH ASPHYXIA

- Assessment must be done immediately after delivery or birth by
using APGAR scale. These is the abbreviation of A= Appearance/
colour of the baby, P= pulse rate of the baby, G= grimace or
reflex of the baby, A = activity done by the baby and R=
respiration of the baby
- Classification of APGAR score according to the sevearity
0-3 severe birth asphyxia
 3-5 moderate birth asphyxia
5-7 mild birth asphyxia
8-10 good condition (no birth asphyxia)
MANAGEMENT OF BIRTH ASPHYXIA
 Clear the airway by suction and wiping
 Ventilate the baby by using ambubag
 Position the baby in supine position sniffing position
 Keep the new born dry and warm
 Gently stimulate the baby with drying rubbing of back and
extrimities
 If the baby is convulsing have to be given phenorbabitone 10
mg/kg to 20 mg/kg intramascular
 Then the patient should be reffered to hospital for further
management.

The most common complication of birth asphyxia is HYPOXIC

ISCHEMIC ENCEPHALOPATHY which if not well treated
immediately can lead to cerebral palsy.
PREVENTION
There should be the professional health which may help to reduce the
complication during labour
Have to treat early complication of pregnancy like pressure induced
hypertension
Also have to screen for chronic illness like hypertensive

REFERENCE:
 Pocket book of hospital care for children world health
organization
MOHSW, WHO, UNICEF 2002 .IM.
 Management of child with serious infection or or severe
malnutrition, Guidelines for care at first referral level.
 Dar es salaam, Tanzania Ministry of heaelth and social walfare