Multisystem Processes & Disorders


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P12_F1.jpg"}},{"insert":"\n\n"},{"insert":"It\u0027s your third day volunteering in Ghana. The introductory programme is finally over and you are ready to start work.\r\n\r\nYour first task is to treat malnourished children at the local nutrition rehabilitation center (NRC).\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P12_F2.jpg"}},{"insert":"\n\n"},{"insert":"You are introduced to your first patient: 14-month-old Ama, who is accompanied by her mother, Anita. They were referred by a local doctor, who noted that Ama was malnourished.\r\n\r\nA quick set of questions confirms that Ama has no acute complaints or known chronic illnesses.\n"}]}


{"ops":[{"insert":"Ama was born at term via vaginal delivery, following an uncomplicated antenatal period. Her birth weight was 2500 grams, which is towards the lower end of normal for Ghana.\r\n\r\nAll vaccines are up to date, as per her immunization card.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P12_F4.jpg"}},{"insert":"\n\n"},{"insert":"Ama was exclusively breastfed initially. She was introduced to liquids at three months of age, and to solids at six months. Importantly, Anita still continues to breastfeed her.\r\n\r\nHowever, Anita and her husband live a hand-to-mouth existence and are often unable to provide their daughter with sufficient food.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P12_F5.jpg"}},{"insert":"\n\n"},{"insert":"Ama\u0027s heart rate is 130 bpm (normal: 98-140), respiratory rate is 25 cpm (normal: 22-37), and blood pressure is 90\/50 mmHg (normal: 72-104\/37-56). Her underarm temperature is 94 \u00b0F (34.4 \u00b0C).\r\n\r\nShe weighs 6.5 kg and her length is 66 cm; both measurements are below the 5th percentile. Her weight-for-height z-score is -3.2, and her height-for-age z-score is -3.4.\r\n\r\nYou also measure her upper arm circumference which is 116 mm (normal: \u2265115) .\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P12_F6.jpg"}},{"insert":"\n\n"},{"insert":"During the general examination, you note that Ama is lethargic. Her skin is pallid and scale-like, with scattered areas of hypo- and hyperpigmentation all over. Bilateral 2+ pitting ankle edema is present.\r\n\r\nExamination of the abdomen reveals mild hepatomegaly and moderate ascites. The cardiopulmonary examination is normal.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P12_F7.jpg"}},{"insert":"\n\n"},{"insert":"\u0022Anita, could you please give Ama some of this food?\u0022, you say, handing over some ready-to-use therapeutic food (RUTF). However, after 10 minutes, Ama still has not eaten anything.\n"}]}


{"ops":[{"insert":"What is your diagnosis?\n"}]}
1. Mild malnutrition
2. Moderate malnutrition
3. Severe malnutrition


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P12_F9.jpg"}},{"insert":"\n\n"},{"insert":"You open your mouth - and then close it again.\r\n\r\nAfter all, the clinical findings indicate a higher degree of malnutrition.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P12_F10.jpg"}},{"insert":"\n\n"},{"insert":"You realize that Ama has severe malnutrition, and mention this to Anita, who starts crying.\r\n\r\nYou do your best to console her while pondering the management.\n"}]}


{"ops":[{"insert":"How will you manage her?\n"}]}
1. As an inpatient
2. As an outpatient


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P12_F6.jpg"}},{"insert":"\n\n"},{"insert":"You consider treating Ama as an outpatient but then discard the idea. She needs close attention.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P12_F13.jpg"}},{"insert":"\n\n"},{"insert":"You realize that Ama fulfills the WHO criteria for the inpatient management of malnutrition and instruct your staff accordingly.\r\n\r\nYou explain this to Anita and reassure her that you\u0027ll be doing everything possible. In parallel, you order a panel of relevant investigations.\n"}]}


{"ops":[{"insert":"As per your orders, the staff members bring in an incandescent lamp and blankets to swaddle Ama in. They also educate Anita about the kangaroo technique.\r\n\r\nYou focus on Ama\u0027s nutrition and ponder what should be done.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P12_F16.jpg"}},{"insert":"\n\n"},{"insert":"You consider starting Ama on F50 formula but then stop.\r\n\r\nWhat F50?! The only therapeutic formulas available are F75 and F100.\n"}]}


{"ops":[{"insert":"You consider starting off with the F100 formula but then discard the idea.\r\n\r\nToo many calories, too soon.\n"}]}


{"ops":[{"insert":"You decide to start Ama on the F75 formula. You also commence folic acid and vitamin A supplementation.\n"}]}


{"ops":[{"insert":"Remembering that severely malnourished children frequently have underlying bacterial infections as well, you now turn your attention towards a suitable antibiotic regimen.\n"}]}


{"ops":[{"insert":"What will you prescribe?\n"}]}
1. Trimethoprim/sulfamethoxazole
2. Amoxicillin
3. Ciprofloxacin


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P12_F21.jpg"}},{"insert":"\n\n"},{"insert":"You consider prescribing ciprofloxacin - but then discard the idea.\r\n\r\nWhy run the risk of musculoskeletal adverse events when a more appropriate agent is available?\n"}]}


{"ops":[{"insert":"You consider prescribing amoxicillin - but then discard the idea.\r\n\r\nThis isn\u0027t the most appropriate antibiotic choice.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P12_F23.jpg"}},{"insert":"\n\n"},{"insert":"You decide to prescribe trimethoprim\/sulfamethoxazole, as this is the first-line agent in malnourished children who do not show signs of infection.\r\n\r\nWith the initial management sorted out, you turn towards Anita and let her know that you\u0027ll be keeping a close watch over Ama over the next several days.\r\n\r\nWith that done, you turn your attention towards the next patient of the day.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P12_F24.jpg"}},{"insert":"\n\n"},{"insert":"The following day, you review Ama\u0027s lab results. The only finding of significance is moderate anemia, with a hemoglobin level of 7.9 mg\/dL (normal: 9.5-13.0).\r\n\r\nBased on this, you decide to start her on oral iron supplementation.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P12_F25.jpg"}},{"insert":"\n\n"},{"insert":"A week passes. Ama\u0027s condition has rapidly improved over time. Over the last three days alone, she has gained 6 g\/kg of body weight.\r\n\r\nShe is not lethargic anymore, the ascites have vanished, and the peripheral edema has gone down significantly. Her appetite has also increased massively.\r\n\r\nYou consider whether a change in nutrition is necessary.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P12_F9.jpg"}},{"insert":"\n\n"},{"insert":"You consider stopping the formula feeds - but then abandon the idea.\r\n\r\nAfter all, Ama hasn\u0027t achieved catch-up growth yet. There is yet much to do.\n"}]}


{"ops":[{"insert":"You consider continuing F75 formula feeds for a while more, but then abandon the idea.\r\n\r\nThis formula just isn\u0027t enough for her current nutritional needs.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P12_F21.jpg"}},{"insert":"\n\n"},{"insert":"You realize that Ama has entered the rehabilitation phase, and decide to gradually transition her to F100 formula feeds over time.\r\n\r\nYou also make sure to continue the iron, folic acid, and vitamin A supplements.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P12_F30.jpg"}},{"insert":"\n\n"},{"insert":"After another two weeks, Ama shows dramatic improvement. She has reached her targeted weight goal, while her appetite has diminished to normal levels. The peripheral edema has completely subsided.\r\n\r\nYou realize that it is finally time for discharge, and inform Anita of this. She is overjoyed.\n"}]}


{"ops":[{"insert":"You inform Anita that she\u0027ll need to bring Ama back to your specialized clinic for malnourished children in a week\u0027s time.\r\n\r\nWhile you appreciate that there is very little you can do to help her socioeconomic circumstances, you inform her that your staff will try to enroll Ama in a food-aid program.\r\n\r\nYou stress that treating Ama every six months for worm infestations will help prevent malnutrition, as will seeking medical aid early on, if she catches an illness.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/P12_F32.jpg"}},{"insert":"\n\n"},{"insert":"\u0022Thank you so much, doctor. I\u0027m so grateful!\u0022, says a very happy Anita.\r\n\r\n\u0022It\u0027s a pleasure\u0022, you say while waving at Ama as she heads out with Anita.\n"}]}


{"ops":[{"insert":"As you head back to your boarding house, you feel proud of your decision to volunteer here.\r\n\r\nBeing a doctor is all about making a difference in people\u0027s lives: and here, you\u0027re making a big difference indeed.\r\n\r\nWell done!\n"}]}

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