A case of Patient AB, 8yrs.

old, female born on February 2,2002 was admitted at

Xavier University- Community Health Care Center last September 8, 2010 at 7pm with
chief complaints of cough for 4 months and severe malnutrition. With an admitting
diagnosis of Severe malnutrition, probably Kwashiorkor. According to the brother, the
client’s decrease of appetite and cough started on June 2010 with yellowish sputum
progressing to greenish sputum. On august 2010, the client had a marked weight loss
characterized by the loss of subcutaneous tissues. They never seek for medical care
due to lack of resources and means of transportation. In the morning of September 8,
2010, a group of German doctors visited the client’s place, who was then referred to
XUCHCC due to severe malnutrition on the same day.

According to informant, patient’s father died last 2008 due to severe productive
cough with an emaciated and thin appearance with complaints of back and chest pain
for more than 4 months. A year after (on 2009), patient’s mother died due to the same
reasons as stated above. Place of prenatal care: New Imbatog Kalabugao Health
Center.

During Intrapartum her mother visited the health care center only once. She
delivered the patient via Normal Spontaneous Vaginal Delivery. There was no
immunization found on patients’ chart due to limited access to health care facilities
(residence is far from Barangay Health Center- around 3km and without means for
transportation).

Upon assessment, her Vital signs were: T=37.7 °C; P= 140 bpm; R= 59 cpm and
Oxygen Saturation of 91%. Blood Pressure was not taken due to unavailability of BP
cuff appropriate for patient’s mid-arm circumference of 12 centimeters. She stands 106
cm and weighs 13.5 Kgs with the BMI of 12.01 which indicates more than 20 percent of
ideal body weight.

Patient looks thin and severe wasting of muscles and subcutaneous tissues.
Generalized weakness noted. Bloating of abdomen is readily observed and has
edematous legs. Patient also slouches and walks slowly.

Prior to hospitalization she takes a bath daily with efforts of conserving water or
sometimes bathes herself on the riverside; uses slippers only when going to school;
brushes teeth daily using salt. In her hospital stay she has never taken a full bath, only
when sponged bath by student nurses; hair not fixed; does not brush her teeth; without
slippers or any other footwear; does not have underwear and changes clothing only
when soiled. Patient wears loose clothing and changes clothing only when soiled. She
has an unpleasant, rotten cheese-like smell body odor. She has a small frame body
built. SN noted generalized pallor. Patient has failure to thrive.
 Patient has a brown complexion, flaky, rough and dry skin. On Sept. 21, 2010,
her body temperature was 38.90 °C and appeared diaphoretic and skin was cold and
clammy when touched. Freckles on forehead and ulceration on both knees 3cm in
diameter and buttocks 5cm in diameter were also noted. Bruises on both knees
measuring 6cm in diameter was also noted.

Patient’s hair was light brown in color, dry, dull, thin in texture and was easily
pulled out. It was minimal in amount but evenly distributed. Her sclera were white with
pale palpebral conjunctiva. SN noted periorbital edema on both eyes. Her lips was
pinkish to pal in color as well as her buccal mucosa. Teeth were yellowish in color and
cavities were noted on lower molars on both sides. Her tongue was pale and dry. Her
nail beds were pinkish to pale in color and firm, capillary refill in the upper extremities
was more than 2 seconds while in the lower extremities, it was more than 3-4 seconds.
Texture was fissured and frigid.

During auscultation, patients’ PMI was 140 bpm and was heard on left sterna
border on third intercostals space. A Pitting Edema of grade 4 on the left foot and grade
1 on the right foot was noted. She had cough for 4 months and was productive with a
whitish colored sputum in minimal amount. Patient’s usual frequency of urination was 5-
6x a day and was changed to 1-2x per day during hospitalizations.

Patient’s respiratory pattern was fast and shallow and labored in breathing
indicating Kussmaul’s Respiration. She was tachypneic with a rate of 59cpm.
Decreased fremitus heard in anterior and posterior chest. Chest expansion was less
than 3 inches with deep inspiration noted. Use of sternocleidomastoid muscles as an
accessory muscle during breathing was noted. Sternum was projecting and protruding
during breathing. Diminished lung sounds and crackles were heard on both lung fields.
Patient appears weak, irritable and restless.

Her usual diet for breakfast, lunch and dinner was a raw “camote” or
“bulanghoy” according to informant. She had decreased appetite since June 2010.
Informant was not so certain with the numerical value of patient’s weight but he reported
a marked weight loss characterized by decreases subcutaneous fats and muscles on
extremities. She has a poor skin turgor and mucous membranes was pale and moist.
Her mid-arm circumference measures 12cm and thigh circumference measures 21cm.
Facial, periorbital, abdominal and bipedal pitting edema were noted and a dependent
edema on both legs. Ascites was also present and her abdominal size was 67cm.

Patient does not take any vitamins or food supplements due to financial
constraints. Few months after the death of parents, the primary source of food has been
“camote” and “bulanghoy” from their backyard due to inadequate financial resources.
She seldom eats rice, fish and vegetables (once a week) from the income they obtain
from selling “camote” and “bulanghoy”. Source of drinking water at home is from a
water-pump about 500 meters from home. During hospital stay, they get water from the
comfort room. As compared to eating meals, patient is observed to have increased
desire for fluids. On September 20, 2010, she drank a total of 200cc at night without
eating her meals.

Her usual bowel pattern was once every 2-3 days, dark brown and hard on
minimal amount. Constipation was experienced. Her usual bladder habit was 5-6x a day
prior to admission and was reduced to 2-3x a day during admission, yellow-orange in
color, 50-100cc in amount every urination. Bladder was not palpable due to abdominal
bloating. Abdomen was non tender and firm and measures 67cm. Decreased bowel
sounds on four quadrants was noted.

Patient’s daily activities at home was doing some of the household chores,
playing with neighborhood children. But limitations were imposed by condition; she can
no longer play and go to school. She sleeps 8-10 hours a day and naps 1-2 hours a
day. Irritability was reported upon awakening. Generalized weakness noted; appears
tired and exhausted.

There was an increase of 148bpm of heart rate and 62cpm of respiratory rate
when asked to perform activity during assessment. She appears irritable and
uninterested to the surroundings. Her posture was relaxed, slouchy and weak. She
often lies on bed and complained of walking within the room premises.

Patient’s brother expressed that financial problem was a stress factor for them
and considered it as a major problem. Patient was less active during onset of illness
and easily gets tired when doing such activities. Concerns of separation, helplessness,
hopelessness were also expressed by the patient’s brother. Upon assessment, the
patient was observed to be irritable, restless and seems uninterested with her
surroundings.

The patient transfused with blood once on September 13, 2010. Patient’s skin
was rough, dry and intact with a poor skin turgor for more than 2-4 seconds.
Generalized weakness was also exhibited by the patient. Her muscle tone was weak,
poor and underdeveloped. Her gait was poor, unstable and she walks very slowly.

Vaginal discharges of yellow colored secretions in minimal amount were noted

on her panties as observed by the patient’s brother. The patient does not perform Self
examination due to underdeveloped breasts.

The patient cries and avoids everyone especially when she is encouraged to eat.
Patient rarely speaks and not in complete sentences, but she is able to nod to agree
and to roll her face away to disagree.

The patient’s dominant language is Bisaya and is unable to read and

comprehend. The patient did not attend kindergarten due to financial constraints,
proceeded to first grade last 2008, and stopped after the death of her father. The
patient’s personality development appears to be non-active or dormant.

On September 21, 2010, another SN reported that patient collapsed in the

comfort room due to dizziness, but was able to stand through the help of the patient’s
brother.

Patient is drowsy and has flat affect and has no delusions and hallucinations. Her
memory can’t be assessed because she does not respond. Her brother reported that
her speech pattern was weak, slow and low-pitched. Facial droop is seen as facial
edema on both cheek and patient has poor or lacks interest in eating.