Paediatric-History taking and physical examination for a malnourished child

Paediatric-History taking and physical examination for a malnourished childCreated OnApril 22, 2020Last Updated OnApril 22, 2020byadmin You are here: Main Clinical Examination Paediatric-History taking and physical examination for a malnourished child < All Topics Table of Contents History taking: Ask about patient’s information – name, age, gender and etc Ask about chief complaint and relevant history of presenting illness Changes in appetite and recent oral intake (quantity and quality of diet) Recent change in weight Recent swelling of feet Associated symptoms such as diarrhoea, fever, cough and decreased urine output Symptoms of micronutrient deficiencies: Iron – fatigue, anaemia, decreased cognitive function, headache, glossitis, nail changes Iodine – mental retardation, neck swelling (goiter) Vitamin D – poor growth, skeletal deformities Vitamin A – night blindness, hair changes, xerophthalmia, poor growth Folate – glossitis, anaemia, neural tube defects (in foetuses of women without folate supplementation) Zinc – anaemia, dwarfism, abdominal distension due to hepatosplenomegaly, poor wound healing, hyperpigmentation, hypogonadism, recurrent infections due to poor immune response Ask about systemic review Recurrent infections Respiratory symptoms Vomiting or diarrhoea with or without food triggers  Dysphagia Snoring and sleep apnoea Central nervous system abnormalities Ask about antenatal and birth histories Maternal age, gravity and parity during pregnancy Pregnancy health history – history of weight gain, prenatal care, substance or cigarette use, nutrition, unusual nutritional practices, general complications, bleeding, infections, fever and toxaemia Mode of delivery and history of birth trauma or complications Neonatal medical history – gestational age determined at birth, intrauterine growth restriction, Apgar scores at birth, birth weight, length, and head circumference with percentiles, neonatal course and complications (sepsis, jaundice, feeding intolerance or difficulties) Ask about past medical/surgical history Recurrent diarrhoea or pneumonia Recurrent or recent thrush (immunosuppression) Other chronic disease, such as cancer Recent sick contact with infectious diseases such as TB and measles Allergies Ask about drug history Review current and past medications Drug allergies Ask about dietary supplements Ask about feeding or nutrition history The child’s eating habits (observe the child eating will be useful) and caloric intake Frequency and timing of meals Evaluate for picky eating or food refusal Request for a food diary for three days to measure caloric intake Eating habits inside and outside of the home (daycare and school) Parental or siblings’ eating habits at the same age as the patient Infant feeding history including duration of breastfeeding, use of breast milk substitutes, age and diet at weaning Preparation of formula milk if the child is formula-fed (frequency, type of formula, mixing technique including number of scoops of milk powder and volume of water) Feeding problems such as poor suckling or difficulty swallowing Caregiver’s knowledge – nutrition and feeding, dietary beliefs, religious and cultural beliefs about food Ask about family history Family structure Prior child with growth problems History of tuberculosis or HIV Ask about immunization history ask if the patient has completed vaccinations according to the national vaccination schedule and any associated complications Ask about developmental history – maybe associated with developmental delay or regressed milestones Ask about social history Number of living parents or other caregivers Number of siblings and birth order of the patient Parent-child interaction Parents’ occupation Household income Availability of food Housing environment – crowding, clean water source, and sanitary facilities History of abuse or neglect Family substance abuse or addiction Violence or chaotic family structure Family or cultural concepts on feeding and specific foods Physical examination: Vital signs evaluation: Blood pressure: assess for hypotension due to shock (hypovolemia due to dehydration or septic shock) Heart rate: tachycardia in shock or infection Temperature: assess for fever or hypothermia Respiratory rate: maybe increased Systems/body parts Signs Deficiencies/ causes General appearance  Reduced weight for height Calories Skin and hair Pallor Anemias (iron, vitamin B12, vitamin E, folate, and copper) Edema Protein, thiamine Nasolabial seborrhea Calories, protein, vitamin B6, niacin, riboflavin Dermatitis Riboflavin, essential fatty acids, biotin Photosensitivity Dermatitis Niacin Acrodermatitis Zinc Follicular hyperkeratosis (sandpaper-like) Vitamin A Depigmented skin Calories, protein Purpura Vitamins C, K Scrotal, vulval dermatitis Column 3 Value 11 Alopecia Zinc, biotin, protein Depigmented, dull hair, easily pluckable Protein, calories, copper Dry hair Vitamins E and A Systems/body parts Signs Deficiencies/ causes Subcutaneous tissue Decreased Calories Poor adaptation to dark Vitamins A, E, zinc Eye Color discrimination, Bitot spots, xerophthalmia, keratomalacia Vitamin A Conjunctival pallor Nutritional anemias Fundal capillary microaneurysms Vitamin C Angular palpebritis, corneal revascularization Vitamin B2 Systems/body parts Signs Deficiencies/ causes Face, mouth and neck Moon facies Kwashiorkor Simian facies Marasmus Angular stomatitis/cheilitis Riboflavin, iron, vitamins B6, niacin Bleeding gums Vitamins C, K Atrophic papillae Riboflavin, iron, niacin, folate, vitamin B12 Smooth tongue Iron Red tongue (glossitis) Vitamins B6, B12, niacin, riboflavin, folate Magenta tongue Vitamin B2 Parotid swelling Protein Caries Fluoride Anosmia Vitamins A, B12, zinc Hypogeusia (reduced ability to taste) Vitamin A, zinc Goiter Iodine Systems/body parts Signs Deficiencies/ causes Cardiovascular Features of heart failure: shifted apex beat, bilateral pedal edema, gallop rhythms, bibasal crepitations Thiamine, selenium, nutritional anemias Abdomen Abdominal distension due to muscle weakness Muscle weakness Hepatomegaly Zinc Hepatosplenomegaly Protein-energy Genital Hypogonadism Zinc Musculoskeletal Cranial bossing, wide fontanel, enlarged epiphysis, genu valgum or varum, metaphyseal widening Vitamin D Costochondral beading (rachitic rosary) Vitamin D, C Subperiosteal hemorrhage Vitamin C, copper Craniotabes Vitamin D, calcium Tender bones Vitamin C Tender calves Thiamine, selenium, vitamin C Spoon-shaped nails (koilonychia) Iron Muehrcke’s line (transverse white nail line without denting) Protein Loss of deep tendon reflexes of the lower extremities Vitamins B1 and B12 Systems/body parts Signs Deficiencies/ causes Neurologic Sensory and motor neuropathy Thiamine, vitamins E, B6, B12 Ataxia, areflexia Vitamin E Ophthalmoplegia Vitamin E, thiamine Tetany Vitamin D, Ca2+, Mg2+ Retardation Iodine, niacin Dementia, delirium Vitamin E, niacin, thiamine Poor position sense, ataxia Thiamine, vitamin B12 Assessment of nutritional status Dietary assessment: Assess the past and current intakes of nutrients through: 24-hour dietary recall Food frequency questionnaire Dietary history since early life Food diary technique Observed food consumption Anthropometry: Measure length/height, weight, head circumference, mid-upper arm circumference. Measurement of length: for children under 2 years old Use a wooden measuring board (sliding board) to measure the length of the child lying down to the nearest millimetre Measurement of height: for children more than 2 years old or older Use either a stadiometer or a portable anthropometer to measure the height of a child to the nearest millimeter Measure the child in standing position with the head in the Frankfurt position (a position where the line passing from the external ear hole to the lower eye is parallel to the floor) During measurements, the shoulders, buttocks and the heels should touch the vertical stand Measurement of weight Use a weighing sling (spring balance/Salter scale) to measure the weight of children under 2 years old, to the nearest 0.1kg Use a beam balance for children above 2 years old to the nearest 0.1kg Measurement of head circumference Measure along the supra-orbital ridge anteriorly and the occipital prominence posteriorly, using a flexible, non-stretchable measuring tape around 0.6cm wide, to the nearest millimeter Usually used to assess chronic nutritional problems in children under 2 years old (not useful after 2 years old) Measurement of mid-upper arm circumference It measures fat free mass in which a low reading indicates a loss of muscle mass It is the circumference of the upper arm at the midway between the shoulder tip and the elbow tip on the left arm The mid-arm point is determined by measuring the distance from the shoulder tip to the elbow and dividing it by 2 MUAC is measured by a special tape which has 3 colors: Red colour – severe acute malnutrition Yellow colour – moderate acute malnutrition Green colour– normal nutritional status Wasting 6-24 months old 25-36 months old 37-60 months old Moderate <125mm <135mm <140mm Severe <120mm <125mm <135mm Laboratory: Haemoglobin level Stool examination for ova and parasites Urine dipstick and microscopy for albumin, sugar and blood Hair, nails and skin analysis for micronutrients Measurement of individual nutrient in body fluids Plasma albumin level Template for pediatric clerkship presentation for a malnourished child Basic structure for case presentation: duration should ideally be around 8-10 minutes Chief complaint: Name is a age year-old boy/girl with underlying any chronic diseases or active diseases was brought to/presented to the hospital with a chief complaint of main presenting symptom with duration or was electively admitted for evaluation of presenting problem (reduced appetite/weight change/swelling of feet), or for follow up a previously diagnosed disease with onset of diagnosis **only include the race and ethnicity of the patient if it is relevant **other information that maybe...

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