Clinical Assessmentã The Trustee of the Wellcome Trust 1998Reviewed by: Dr R H Behrens, Hospital for Tropical Diseases, London and Dr W A M Cutting, Department of Child Life and Health, The University of Edinburgh, UKPicture: A skin pinch test being performed on an Egyptian child with severe dehydration due to diarrhoea. Copyright Copyright holder unknown. Image supplied by Cutting WAM.Image references ################ .\IMAGES\T22303a.jpg Contents Click on the underlined text to jump tothat screen. Screen3 Objectives 4Introduction 5Objectives of Clinical Assessment 9Assessment 10 Degree of Dehydration 16 Assessments 19 Clinical Type of Diarrhoea 22 Assessment 23 Nutritional Status and Feeding Practices 30 Assessments 32 Concurrent Illness and Immunization Status 35 Assessment 36 The Role of Diagnostic Investigations 39 Assessment 40 Tutorial Assessments 43Summary Underlined text is interactive. Click on underlined text to view extra information or to jump to another screen. Picture: Assessment of a child with persistent diarrhoea and severe malnutrition. Copyright Copyright Image from Behrens RH.Image references ################ .\IMAGES\T45350c.jpg ObjectivesAt the end of this tutorial you should be able to: 1. detect different degrees of dehydration from the physical examination of a patient with diarrhoea 2. name the type of diarrhoea from the clinical history and appearance of the stool 3. assess a child’s nutritional status and evaluate feeding practices 4. diagnose any concurrent illness 5. determine a child’s immunization status 6. summarize the role of diagnostic investigations in a patient with diarrhoea Image references ################ IntroductionDiarrhoea Diarrhoea is: · an increase in the number, volume and water content of stools · a global cause of much illness and death· a major factor in childhood malnutrition This tutorial is about the clinical assessment of a patient with diarrhoea. Accurate clinical assessmentis essential to plan correct treatment.Picture: A malnourished Nigerian child with diarrhoeal dehydration being examined. Copyright Image from WHO Photo Library courtesy of Lejneu A. Diarrhoea morbidity and mortalityEach year there are: · approximately 3.3 million deaths due to diarrhoea, 80% in children under 2 years of age · over 1 billion episodes of diarrhoea, most in the developing world · 5 - 10 million travellers affected by diarrhoea Image references ################ .\IMAGES\T34919.jpg Objectives of Clinical Assessment Objectives of Clinical AssessmentImage references ################ Objectives of Clinical Assessment - 1Aims - 1 Any patient with loose, watery or bloody stools should be assessed. Clinical assessment aims to: · determine the degree of dehydration (see table) · diagnose the clinical type of diarrhoea (see table) Further objectives of clinical assessment are given on screen 7. Degrees of Dehydration (WHO 1995)1 No signs of dehydration Some dehydration Severe dehydration 1. These replace the four categories of dehydration that were previously recognized. Clinical Types of Infectious Diarrhoea Acute watery diarrhoea Acute bloody diarrhoea (dysentery) Persistent diarrhoea Degree of dehydrationThe degree of dehydration is important because dehydration: · is a common consequence of diarrhoea, especially acute watery diarrhoea · can lead to death if it is severe and is not treated quickly Assessment and treatment of dehydration is a central feature of the management of a patient with diarrhoea.Categories of dehydrationThe four categories of dehydration that were previously used are: · no dehydration · mild dehydration Now broadly combined · moderate dehydrationinto some dehydration. · severe dehydrationClinical type of diarrhoea Picture: A bloody stool. This suggests shigellosis and needs prompt antibiotic treatment. Image from Behrens RH. The clinical type of diarrhoea is important because the various types require different treatment. For example: · acute bloody diarrhoea (see picture) needs antibiotic treatment · persistent diarrhoea needs careful dietary management Image references ################ .\IMAGES\T25584p.jpg Objectives of Clinical Assessment - 2 Aims - 2 Clinical assessment of a child with diarrhoea also aims to: · determine the nutritional status (see table) and evaluate feeding practices · diagnose any concurrent illness· determine the immunization status Classification of Malnutrition Severe malnutrition Marasmus Kwashiorkor Marasmic kwashiorkor Vitamin and mineral deficiencies Vitamin A deficiency Other deficiencies, eg. anaemiaPicture: Measurement of height so as to calculate weight for height. This is used to help determine the degree of malnutrition. Copyright Image from Medicins Sans Frontieres. Immunization status Every opportunity to check immunization status should be taken. In particular, measles is: · preventable by vaccination · often accompanied by diarrhoea · a risk factor for subsequent severe and persistent diarrhoea · a major cause of death and disability in its own right Vaccination for measles is a highly effective measure to prevent diarrhoeal diseases. Nutritional status The child’s nutritional status is important because: · malnutrition is an important consequence of diarrhoea · diarrhoea is more likely to be fatal in a child with malnutritionConcurrent illness It is important to diagnose and treat concurrent illness because: · children in the tropics often have more than one serious disease · a diagnosis of diarrhoea does not exclude other illness in the same child Image references ################ .\IMAGES\T45870.jpg Objectives of Clinical Assessment - 3 Stages in the clinical assessment Assessment should follow three stages. These are: 1. clinical history and examination of the stool (see picture) 2. physical examination of the patient 3. diagnostic investigations Picture: A small blood stained loose stool from a Bangladeshi child.Copyright Image from Tubbs HR. Physical examinationIf initial physical examination detects severe dehydration (see screens 11 - 14) it is vital to: · start treatment by intravenous rehydration immediately · complete the history and physical examination later This is because a patient with severe dehydration is at immediate risk of death.Diagnostic investigations Laboratory investigations have only a limited role in the management of a patient with diarrhoea. Image references ################ .\IMAGES\T22776.jpg Objectives of Clinical Assessment: Assessment Are the following statements true or false? Click on the True or False button for each statement. Clinical assessment of a patient with diarrhoea aims to: To return to the start of the section. 1. determine the degree of dehydration 2. establish whether diarrhoea is viral, bacterial or parasitic in origin 3. distinguish between acute and persistent diarrhoea 4. diagnose severe malnutritionCorrect The degree of dehydration should be assessed as one of: · no signs of dehydration · some dehydration · severe dehydrationIncorrect Text 11 pt Arial dark blue goes here Incorrect The degree of dehydration should be assessed as one of: · no signs of dehydration · some dehydration · severe dehydrationCorrect Text 11 pt Arial dark blue goes here Correct Text 11 pt Arial dark blue goes here Incorrect Diagnosis of the pathogen causing diarrhoea is not: · generally possible from the clinical assessment · necessary for treatment in most casesIncorrect Text 11 pt Arial dark blue goes here Correct Diagnosis of the pathogen causing diarrhoea is not: · generally possible from the clinical assessment · necessary for treatment in most casesCorrect Acute and persistent diarrhoea: · are clinically different in many aspects · require different treatmentIncorrect Text explaining the answer (11-pt plain blue) Incorrect Acute and persistent diarrhoea: · are clinically different in many aspects · require different treatmentCorrect Text explaining the answer (11-pt plain blue) Correct Nutritional status should be assessed and severe malnutrition diagnosed.Incorrect Text 11 pt Arial dark blue goes here Incorrect Nutritional status should be assessed and severe malnutrition diagnosed.Correct Text 11 pt Arial dark blue goes hereImage references ################ Degree of DehydrationDegree of Dehydration Image references ################ Degree of Dehydration - 1 The WHO chart ‘Management of the Patient with Diarrhoea’. This chart leads directly on to the correct treatment strategy.Physical examination The degree of dehydration is assessed by physical examination using a standardized WHO chart (see picture). A careful assessment must be made of the patient’s: · general condition and behaviour· eyes· tears· mouth and tongue· thirst· skin turgor (see screen 12) How easy is correct assessment of the degree ofdehydration? 1. Look at: Condition Well, alert Restless,Lethargic orirritable unconscious; floppy Eyes Normal Sunken Very sunken and dry Tears Present Absent Absent Mouth & tongue Moist Dry Very dry Thirst Normal, not thirsty Thirsty, drinksDrinks poorly eagerly or cannot drink 2. Feel: skin pinch Returns quickly Returns slowly Returns very slowly 3. Decide NO SIGNSIf two or moreIf two or more OFsigns, includingsigns, including DEHYDRATION one sign, SOMEone sign, SEVERE DEHYDRATION DEHYDRATION 4. Treat (see Plan A Weigh if possible,Weigh the patient, screen 15)then Plan B then Plan CURGENTLYCopyright Image from World Health Organization. The treatment of diarrhoea - a manual for physicians and other senior health workers. WHO/CDR/95.3. Geneva: WHO, 1995. General condition and behaviour Is the child: · well and alert? · restless or irritable? · ‘floppy’, listless, lethargic or unconscious? (The mother can be asked if the child is genuinely lethargic rather than just sleepy)Eyes Are the child’s eyes: · normal? · sunken? · very sunken and dry? (The mother can be asked if she thinks the child’s eyes are normally sunken or more sunken than usual)TearsWhen the child cries vigorously, are tears produced?Mouth and tongueAre the child’s mouth and tongue: · wet? · dry? · very dry? Factors other than dehydration may affect this. For example, has the child recently been drinking or vomiting (wet mouth), or breathing through the mouth (dry mouth)?Thirst Offer the child some water or oral rehydration salts (ORS) solution. Does the child: · drink normally without particular interest, or refuse to drink? · drink eagerly, grasping the cup or spoon and crying if it is withdrawn? · appear unable to drink, or drink poorly because of lethargy or reduced consciousness?How easy is assessment? Accurate assessment of the degree of dehydration is difficult. It requires: · experience· practiceImage references ################ .\IMAGES\Patmgt.gif Degree of Dehydration - 2 Physical examination: skin turgor For this test the skin of the abdomen is pinched, gently pulled and released. Does the skin pinch flatten and go back: · immediately, like a rubber band springing back (see the video)? · slowly, in 0.5 - 1 second? · very slowly, taking more than2 seconds? The skin pinch test is not reliable in children with severe malnutrition (see screen 27).Video: Performing a skin pinch test. The skin pinch in this normally hydrated child returns very quickly. To run the video.Copyright Image and video from United Nations Children's Fund, India. Copyright Copyright Copyright: Image from XXXX.Image references ################ .\IMAGES\Diarrh2.jpg Degree of Dehydration - 3 Additional signs of dehydration Useful signs that are not part of the standard WHO chart include: · pulse rate · peripheral perfusion (see table) · anterior fontanelle in infants · breathing rate and depth Poor Peripheral Perfusion in Severe Dehydration Normal hydration Severe dehydration Skin of lower Warm and dry Cool and moist arms and legs Fingernail beds Pink Blue (cyanotic) Nailbed refilling Less than 1 second More than 2 seconds time11. Time for the blanched area of a pressed nail to refill.Breathing rate and depth A child with severe dehydration often shows acidotic breathing (Kussmaul’s respiration). This is typically: · deep · without chest indrawing In contrast, breathing in pneumonia is typically: · shallow · rapid · accompanied by a cough Anterior fontanelle The anterior fontanelle in infants is: · more sunken than usual in a child with some dehydration · very sunken in a child with severe dehydrationPulse rate As the degree of dehydration increases, the pulse rate rises and blood pressure falls.In severe dehydration the: · radial pulse becomes weak and may not be felt · femoral pulse can usually still be felt · blood pressure may be too low to recordImage references ################ Degree of Dehydration - 4 The WHO chart ‘Management of the Patient with Diarrhoea’. The signs shown in *bold text* are the most valuable in assessing dehydration.Deciding on the degree of dehydration The degree of dehydration is assessed by following the four steps in the WHO chart. Click on the numbers below to see how the chart is used. · Step 1· Step 2 · Step 3· Step 4 1. Look at: Condition Well, alert Restless,Lethargic orirritable unconscious; floppy Eyes Normal Sunken Very sunken and dry Tears Present Absent Absent Mouth & tongue Moist Dry Very dry Thirst Normal, not thirsty Thirsty, drinksDrinks poorly eagerly or cannot drink 2. Feel: skin pinch Returns quickly Returns slowly Returns very slowly 3. Decide NO SIGNSIf two or moreIf two or more OFsigns, includingsigns, including DEHYDRATION one sign, SOMEone sign, SEVERE DEHYDRATION DEHYDRATION 4. Treat Plan A Weigh if possible,Weigh the patient, then Plan B then Plan CURGENTLYCopyright Image from World Health Organization. The treatment of diarrhoea - a manual for physicians and other senior health workers. WHO/CDR/95.3. Geneva: WHO, 1995. Step 1 1. For each sign, the most descriptive term from column A, B or C is selected.Step 2 2. Column C is looked at first. If two or more signs from column C have been selected, including at least one key sign (indicated in bold text), then the patient has severe dehydration.Step 33. If severe dehydration is not present, column B is looked at next. If two or more signs from column B have been selected, including at least one key sign (indicated in bold text), then the patient has some dehydration. (Some signs from column C may have been selected, but not enough to diagnose severe dehydration.)Step 4 4. If neither severe dehydration nor some dehydration is present, the patient has no signs of dehydration. (The patient probably has a fluid deficit but not enough to cause significant clinical signs.) Image references ################ .\IMAGES\Patmgt.gif Degree of Dehydration - 5 Selecting a treatment plan Assessment of the degree of dehydration leads directly on to the correct treatment plan (see table).How common are children with some or severe dehydration?Treatment According to the Degree of Dehydration Degree ofLoss inEstimated dehydration body weightfluid deficitTreatment plan No signs <5% <50 A. Home therapy ofml/kg to prevent dehydrationdehydrationand malnutrition Some 5 - 10% 50 - 100B. Oral dehydration1 ml/kg rehydrationtreatment with ORS solution Severe >10% >100 C. Urgent dehydration1 ml/kg intravenous rehydration1. A child with some or severe dehydration should be weighed to estimate how much fluid to give.Some or severe dehydration In general, of every 100 children with diarrhoea seen in a hospital outpatient service: · 5 - 10 will have some dehydration · only one will have severe dehydration This tutorial is biased towards identifying these children because they are at greatest risk.Estimation of fluid deficit For example, a child with some dehydration who weighs 5 kg unclothed has a fluid deficit of: Fluid deficit = [50 - 100] ml/kg x 5 kg = 250 -500 ml If a scale to weigh the child is not available, the child’s weight should be estimated from a growth chart. Image references ################ Degree of Dehydration: Assessment - 1Are the following statements true or false? Click on the True or False button for each statement. According to the WHO classification, signs of severe dehydrationinclude: To return to the start of the section. 1. patient is restless and irritable2. eyes are very sunken and dry3. mouth and tongue are very dry4. skin pinch goes back very quicklyCorrect Text explaining the answer (11-pt plain blue) Incorrect This indicates that there is some dehydration. A patient with severe dehydration is likely to be lethargic or unconscious.Incorrect Text explaining the answer (11-pt plain blue) Correct This indicates that there is some dehydration. A patient with severe dehydration is likely to be lethargic or unconscious.Correct This is a sign of severe dehydration.Incorrect Text explaining the answer (11-pt plain blue) Incorrect This is a sign of severe dehydration.Correct Text explaining the answer (11-pt plain blue) Correct This is a sign of severe dehydration.Incorrect Text explaining the answer (11-pt plain blue) Incorrect This is a sign of severe dehydration.Correct Text explaining the answer (11-pt plain blue) Correct Incorrect This indicates that there is no dehydration. The skin pinch of a patient with severe dehydration is likely to go back very slowly.Incorrect Text explaining the answer (11-pt plain blue) Correct This indicates that there is no dehydration. The skin pinch of a patient with severe dehydration is likely to go back very slowly. Image references ################ Degree of Dehydration: Assessment - 2What is this boy's degree of dehydration? Run the video and assess the following: · general condition · eyes · thirst or ability to drink Click the buttons for the answers. A skin pinch returns in 2 - 3 seconds. What do you conclude about the child's degree of dehydration? For the answer. To run the video. To return to the start of the section. Copyright Image and video from United Nations Children's Fund, India. Copyright Copyright Copyright: Image from XXXX. Answer: General condition The boy appears to be extremely apathetic and is nearly comatose. This should be recorded as 'column C' in the WHO chart.Answer: Eyes The boy's eyes are sunken but are not very sunken. This should be recorded as 'column B' in the WHO chart.Answer: Thirst/ability to drink A child in this condition is unable to drink. This should be recorded as 'column C' in the WHO chart.Answer: Degree of dehydration The boy has the following signs of severe dehydration: · lethargic or unconscious · not able to drink · very slow return of a skin pinchImage references ################ .\IMAGES\Diarrh3.jpg Degree of Dehydration: Assessment - 3What is this boy's degree of dehydration? Run the video and assess the following: · general condition · eyes · thirst or ability to drink Click the buttons for the answers. A skin pinch returns in less than 1 second. What do you conclude about the child's degree of dehydration? For the answer. To run the video. To return to the start of the section. Copyright Image and video from United Nations Children's Fund, India. Copyright Copyright Copyright: Image from XXXX. Answer: General condition The boy appears to be irritable. Notice how he cries when the rehydration solution is withheld. This should be recorded as 'column B' in the WHO chart.Answer: Eyes The boy's eyes are normal and not sunken. This should be recorded as 'column A' in the WHO chart.Answer: Thirst/ability to drink The child appears thirsty and eager to drink. This should be recorded as 'column B' in the WHO chart.Answer: Degree of dehydration The boy has the following signs of some dehydration: · restless and irritable · eager thirst These are both important (starred) signs in the chart and therefore the assessment is for plan B. Image references ################ .\IMAGES\Diarrh5.jpg Clinical Type of DiarrhoeaClinical Type of Diarrhoea Image references ################ Clinical Type of Diarrhoea - 1 The clinical type of diarrhoea is assessed by taking a history and from stool examination. Questions about the diarrhoea The child’s mother should be asked thesesorts of questions. · How long has the diarrhoea been going on? · How many times a day does the child havea bowel movement? · Are the stools of large volume? · Have you seen any blood in the stools (see picture)? · Has the child vomited during the illness? · Has the child had a fever? Stool examination The stool should be carefully examined withthe naked eye, looking especially for blood. Picture: A bloody stool from a patient with shigellosis.Copyright Image from Bennish M. Copyright Copyright Copyright: Image from XXXX. Examination by naked eye Microscopy of the stool is not generally necessary to assess the clinical type of diarrhoea. Image references ################ .\IMAGES\T45899.jpg Clinical Type of Diarrhoea - 2 Interpreting the Clinical History and Stool Examination Clinical typeDefinition from history and stool of diarrhoea Acute wateryLoose or watery stools without visible blood diarrhoea Duration less than 14 days1 Acute bloodyLoose or watery stools with visible red blood2 diarrhoeaDuration less than 14 days1 PersistentLoose or watery stools with or without visible blood diarrhoea Duration 14 days or more1.Most episodes of acute diarrhoea last less than 5 - 7 days. 2.A history of bloody stools reported by the mother is sufficient for a diagnosis.For related tutorials. Visible blood The definition of visible red blood in the stool excludes: · streaks of blood on the surface of a formed stool · blood detected only microscopically or biochemically · black stools containing digested blood (melaena) Mucus and pus may be present but are not necessary for a diagnosis.Related tutorials Treatment of the three clinical types of diarrhoea is described in the Diarrhoeal Diseases tutorials: · Acute Watery Diarrhoea · Acute Bloody Diarrhoea · Persistent Diarrhoea Image references ################ Clinical Type of Diarrhoea: Assessment Run the video and answer the questions. Which clinical type of diarrhoea do you suspect that this child has? For the answer. What questions should you ask the mother? For the answer. What do you expect to be the most important clinical problem to address? For the answer. To run the video. To return to the start of the section. Copyright Image and video from United Nations Children's Fund, India. Copyright Copyright Copyright: Image from XXXX. Answer: Type of diarrhoea The video shows a high volume diarrhoea that appears to be watery.Answer: Questions to ask You need to ask the mother these sorts of questions. · How long has the diarrhoea been going on? · How often does the child have a bowel movement? · Are the stools of large volume? · Have you seen any blood? · Has the child vomited? · Has the child had a fever?The answers will determine whether the diarrhoea is watery or bloody, acute or persistent.Answer: Clinical problem If the mother confirms the diagnosis of acute watery diarrhoea, then dehydration will probably be the main problem. However, you must also assess the child for malnutrition and concurrent illnesses. Image references ################ .\IMAGES\Diarrh1.jpg Nutritional Status and Feeding Practices Nutritional Status and Feeding Practices Image references ################ Nutritional Status and Feeding Practices - 1 Diarrhoea and malnutritionA feeding history must be taken to be able to advise the mother on: · nutrition during the diarrhoea episode· how a good diet can help prevent diarrhoea in the future Assessment of nutritional status is important for two related reasons. 1. Malnutrition is an important consequence of diarrhoea. 2. Diarrhoea in a child with malnutrition is more likely to be:· severe (high stool volume and frequency) · persistent · fatal For related tutorials.Picture:A child with diarrhoea and severe malnutrition. These conditions can interact to form a ‘vicious circle’, the end result of which is often death.Copyright Image from Behrens RH. Feeding during diarrhoea Correct feeding practice during diarrhoea includes: · breast feeding throughout oral rehydration · restarting solid food after 4 - 6 hours of oral rehydration For details refer to the tutorial Diarrhoeal Diseases: Rehydration and Early Feeding.Malnutrition due to diarrhoeaMalnutrition is particularly likely to be due to: · persistent diarrhoea (persistent diarrhoea-malnutrition syndrome) · repeated episodes of acute diarrhoeaDiarrhoea and malnutrition A child with severe malnutrition and diarrhoea is at a particularly high risk of death.Related tutorials Refer to the tutorial Diarrhoeal Diseases: Epidemiology.Image references ################ .\IMAGES\T45355.jpg Nutritional Status and Feeding Practices - 2 Questions about feeding practices Infants · Is the child breast feeding? If so, how often? · Was animal or formula milk introduced recently?· Are any other foods or liquids given? Older children · What solid food does the child normally eat? · Is oil added to the child’s food?· How much was the child feeding before the illness? · Has feeding during the illness been reduced, increased or unchanged? Picture: Breast feeding protects from diarrhoea and is an important part of nutritional management in an infant with diarrhoea.Copyright Image from John & Penny Hubley. Animal or formula milk If non-breast milk was introduced recently, did the mother notice any change in the stools? Introduction of non-breast milk can sometimes cause or contribute to an episode of diarrhoea.Feeding during the illness If this is a follow-up visit (eg. in a child with persistent diarrhoea), has the mother seen a change in the child’s appetite since the previous visit?OilImage from United Nations Children's Fund, India. It is recommended that a little vegetable oil (see picture) is added to cereal to increase its energy content. Image references ################ .\IMAGES\T26832.jpg .\IMAGES\T45966p.jpg Nutritional Status and Feeding Practices - 3 Marasmus Kwashiorkor Physical examination for severe malnutrition Assessment of nutritional status requires looking for signs of: · severe malnutrition: - marasmus - kwashiorkor - marasmic kwashiorkor · vitamin deficiency Children with diarrhoea and severe malnutrition need referral for hospital treatment. Which type of diarrhoea is most common in malnourished children? Thin, pale weak hair Poor appetite Flakyskin Mildanaemia Apathetic Miserable OedemaNormalhair Hungry Grossmusclewasting Grossly underweight'Worried old man' appearance No fat Large liver Usually underweight Copyright Image from The Wellcome Trust modified from World Health Organization. Readings on diarrhoea. Student manual. Geneva: WHO, 1992.Diarrhoea and severe malnutrition Severe malnutrition: · can occur with acute diarrhoea · is particularly closely linked to persistent diarrhoea (persistent diarrhoea-malnutrition syndrome) Refer to the tutorial Diarrhoeal Diseases: Persistent Diarrhoea.Vitamin deficiencyLeft: Conjunctival xerosis and Bitot’s spot (arrow). The latter is not restricted to vitamin A deficiency. Right: Signs of severe vitamin A deficiency: corneal ulceration. Vitamin A deficiency is very important. Ocular features (xerophthalmia - see pictures) include:· a history of night blindness · dry dull areas (xerosis) on the conjunctiva and cornea · foamy material on the conjunctiva (Bitot’s spots) · ulceration and perforation of the cornea in severe casesImages from Sommer A. A Fieldguide to the Detection and Control of Xerophthalmia. Geneva: WHO, 1978.Image references ################ .\IMAGES\Maraskwr.gif .\IMAGES\T14039b.jpg Nutritional Status and Feeding Practices - 4Dehydration in a child with severe malnutrition The degree of dehydration is difficult to assess in a child with: · marasmus (see picture) · kwashiorkor Signs that remain useful in assessing dehydration are:· dry mouth and tongue· eager thirst· very dry mouth and tongue· cool moist extremities· weak or absent radial pulse Which other condition can resemble severe dehydration? Signs of somedehydration. Signs of severedehydration. Picture: A child with severe malnutrition and diarrhoea. Note the severe wasting, indicating marasmus.Copyright Image from Shulman C. Signs that remain usefulNot all of these signs are present on the standard WHO chart.Other conditions In a child with severe malnutrition, the signs of septic shock and severe dehydration are often similar. Both conditions reflect: · a low circulating volume (hypovolaemia) · poor peripheral perfusionDehydration in marasmus The signs of marasmus include: · loose skin from wasting · sunken eyes · child is fretful and anxious These may suggest dehydration even in a normally hydrated child.Dehydration in kwashiorkor The signs of kwashiorkor include: · oedema · apathy and misery Skin turgor and general condition are not reliable signs in the assessment of dehydration in a child with kwashiorkor.Image references ################ .\IMAGES\T34092.jpg Nutritional Status and Feeding Practices - 5 Anthropometric assessment of malnutrition Diagnosis of Moderate and Severe Malnutrition Weight for Weight forMUACMalnutrition age (%)1 height (%)1 (cm)2 Moderate 60 - 7570 - 8012.5 - 13.5 Severe3 < 60 < 70 < 12.5In addition to physical examination, malnutrition can also be assessed after rehydration from measurements (see table) of: · weight for age· weight for height · mid-upper arm circumference (MUAC) in children aged 1 - 5 years1. Based on US National Center for Health Statistics median values. 2. In children aged 1 - 5 years. 3. With signs of obvious marasmus or kwashiorkor.Weight for ageThis requires that the child’s age is known with reasonable accuracy. This can sometimes be a problem.Weight for height An alternative is to measure the length of the child lying down - weight for length.MUAC Picture: A tricoloured strip being used for measuring MUAC. This method is most useful in emergency situations such as famines.Image from Medicins Sans Frontieres. MUAC is often measured with a tricoloured strip (see picture), which allows classification of the child as: · well nourished · moderately malnourished · severely malnourished Image references ################ .\IMAGES\T45861p.jpg Nutritional Status and Feeding Practices - 6 Monitoring growth To monitor development over time, a child must be weighed regularly and the results plotted on a growth chart. The growth line of a healthy child: · is always between the 3rd and 97th population centiles (the smooth blue andred lines on the graph) · has a similar shape to the reference curve · does not change suddenly (eg. dip) between readings Weight (kg) Time (months) Picture: A growth line showing the weight of one child over the first 24 months of life. The curve shows three patterns of growth: click on the letters A - C for a summary.C A B Copyright Image from The Wellcome Trust. 3rd and 97th centiles Although the 50th centile marks the population median, the growth line of an individual healthy child need not be very close to this value.Changes in growth lines Some irregularity is normal - no children have growth lines as smooth as the reference curve.A (1 - 14 months) The child’s weight was progressing well. The growth curve: · has a slope similar to the reference curve · lies between the 3rd and 50th centiles at all times B (14 - 16 months) The child suffered a sudden loss of weight, probably due to an infection. The growth curve: · sloped suddenly downwards · fell to lie below the 3rd centile C (16 - 22 months) The child regained weight quickly. The growth curve: · sloped rapidly upwards, more quickly than the reference curve (‘catch-up’ growth) · returned to lie between the 3rd and 50th centiles with a slope similar to the reference curveImage references ################ .\IMAGES\Growth1.gif Nutritional Status and Feeding Practices: Assessment - 1 The picture shows a child with diarrhoea and severe malnutrition. What is your diagnosis of the type of malnutrition? Make your diagnosis by clicking on one of the answers below. You should also think about the reasons for your choice.Marasmus Kwashiorkor Marasmic kwashiorkor To return to the start of the section.Copyright Image from Marsden PD. Answer clicked: Marasmus Wrong. The child has these signs of kwashiorkor: · oedema of the lower legs · flaking skinAnswer clicked: Kwashiorkor Correct. The child has these signs of kwashiorkor: · oedema of the lower legs · flaking skinClicked: Marasmic kwashiorkor Wrong. The child has these signs of kwashiorkor: · oedema of the lower legs · flaking skin He has no obvious signs of marasmus. Image references ################ .\IMAGES\T2243.jpg Which patient history best matches each growth line? Image from The Wellcome Trust. Chart A Chart B Chart C Chart D Moveyour mouse over a patientbelow and read the history.Then hold the mouse down and drag the patient to the correct chart. To return to the start ofthe section. {patient_history} Nutritional Status and Feeding Practices: Assessment - 2 1 2 3 4 Well done. You have now finished this assessment.Image references ################ .\IMAGES\Growth2.gif .\IMAGES\Toddler1.gif .\IMAGES\Toddler2.gif .\IMAGES\Toddler1.gif .\IMAGES\Toddler2.gif Concurrent Illness and Immunization StatusConcurrent Illness and Immunization Status Image references ################ Concurrent Illness and Immunization Status - 1 Diagnosis of concurrent illness Among children under 5 years in developing countries, over 70% of all deaths are caused by just five diseases, often in combination. These diseases are: · acute respiratory infection, eg. pneumonia · malnutrition· diarrhoea· malaria· measles (see picture) A diagnosis of diarrhoea, with or without malnutrition, does not exclude another illness in the same child. Picture: A child with severe measles and diarrhoea receiving nasogastric fluids for dehydration. Note the desquamating rash. Copyright Image from Rolfe M. Another illness The main clinical features of the infectious diseases listed include: · fever in a malarious area - malaria · cough and rapid breathing - acute respiratory infection · rash and a history of contact with a child with measles - measles Concurrent disease will require treatment according to approved guidelines. Image references ################ .\IMAGES\T18168.jpg Concurrent Illness and Immunization Status - 2 Immunization status Questions to ask the mother include: · Has the child had any immunizations? If so, which ones?· Has measles vaccine been given? Immunization for measles is usually given at 9 months of age. Measles vaccine should be given to an unimmunized child, based on: · what the mother reports · the child’s immunization record (if available) Picture: Vaccination for measles. Note that the recommended site for intramuscular injection of the vaccine is the lateral thigh. Why is measles so important? Copyright Copyright holder unknown. Image supplied by MERLIN picture library. Measles immunization Measles is one of the diseases included under the WHO Expanded Programme on Immunization. This recommends that all countries immunize against: · poliomyelitis · diphtheria · pertussis · tetanus · measles · tuberculosis (where incidence is high) · hepatitis B · yellow fever (where this is endemic)Importance of measles Measles is: · often accompanied by diarrhoea · a risk factor for subsequent severe and persistent diarrhoea · a major cause of death and disability in its own right Vaccination for measles is a highly effective measure to prevent diarrhoeal diseases. Image references ################ .\IMAGES\T45823.jpg Concurrent Illness and Immunization Status: AssessmentA 2-year-old girl is brought to your health centre with diarrhoea. She has rapid breathing and a cough. Her mother says that the child has had diarrhoea without blood for 6 days and a fever. Are the following statements true or false?Click on the True or False button for each statement.To return to the start of the section. 1. The provisonal clinical diagnosis is persistent diarrhoea with acuterespiratory infection.2. The fever might be due to malaria.Correct Text explaining the answer (11-pt plain blue) Incorrect The diarrhoea is: · acute - duration less than 14 days · watery - no visible blood Acute respiratory infection (eg. pneumonia) is suggested by: · rapid breathing· cough Incorrect Text explaining the answer (11-pt plain blue) Correct The diarrhoea is: · acute - duration less than 14 days · watery - no visible blood Acute respiratory infection (eg. pneumonia) is suggested by: · rapid breathing· cough Correct Malaria should be suspected: · in a malaria endemic area · if the fever has no obvious other cause Remember however that many childhood infections (eg. urinary tract infection, otitis media) can cause a fever.Incorrect Text explaining the answer (11-pt plain blue) Incorrect Malaria should be suspected: · in a malaria endemic area · if the fever has no obvious other cause Remember however that many childhood infections (eg. urinary tract infection, otitis media) can cause a fever.Correct Text explaining the answer (11-pt plain blue)Image references ################ The Role of Diagnostic InvestigationsThe Role of Diagnostic Investigations Image references ################ The Role of Diagnostic Investigations - 1Why are diagnostic investigations not essential? Clinical examination generally cannot identify the pathogen causing diarrhoea.However, laboratory diagnosis: · is not usually necessary forpatient management · may take several days, whereas treatment must be started immediately · often requires resources that are not available Laboratory diagnosis has only a limited role in the management of a child with diarrhoea.When is laboratory diagnosis important?Picture: Stool microscopy showing a trophozoite of Entamoeba histolytica that contains ingested red blood cells (arrows). This is an indication for treatment against amoebic dysentery.Copyright Image from London School of Hygiene and Tropical Medicine. Patient management Management proceeds by: · rehydration according to the degree of dehydration · antimicrobial therapy for specific enteric infections: - cholera, diagnosed as severe acute watery diarrhoea - shigellosis, diagnosed as acute bloody diarrhoea - amoebic dysentery, diagnosed by microscopy - giardiasis, diagnosed as persistent diarrhoea with microscopic confirmation · appropriate nutritional management · treatment of any concurrent illnessLaboratory diagnosis Depending on available resources, identification of the pathogen may be required for: · persistent diarrhoea · determination of antibiotic sensitivity, eg. when treatment has failed At a public health level, characterization of the pathogen is necessary for epidemiological surveillance, eg. in a cholera epidemic. Image references ################ .\IMAGES\T22836.jpg The Role of Diagnostic Investigations - 2 Laboratory diagnosis Techniques to support the clinical assessment and stool examination are: · stool microscopy for polymorphonuclear neutrophils (PMNs) · stool microscopy for parasites · stool culture for bacterial pathogens (see picture) · immunological and nucleic acid based methods What determines which tests areperformed? Picture: A culture of V. cholerae. In a reference laboratory, culture is essential before testing of antibiotic sensitivity. Copyright Image from Centers for Disease Control and Prevention. PMNsA stool sample is stained with methylene blue. A finding of numerous PMNs on light microscopy suggests an invasive bacterial pathogen such as: · Shigella · C. jejuni · non-typhoid Salmonella These pathogens often cause bloody diarrhoea. Faecal PMNs are generally absent in acute watery diarrhoea.Microscopy for parasites Light microscopy of a stool sample may identify: · trophozoites of Entamoeba histolytica - a cause of acute bloody or persistent diarrhoea · cysts or trophozoites of Giardia lamblia - a cause of persistent diarrhoea · oocysts of Cryptosporidium parvum - a cause of acute watery or persistent diarrhoeaStool culture Culture of bacterial pathogens from a stool sample in selective media: · is often the definitive technique · generally takes 2 - 3 days, too long to delay treatment of acute diarrhoea · requires a fresh stool · is very labour intensive and expensiveNucleic acid based methods DNA hybridization assays: · can diagnose pathogenic types of E. coli · are not widely available and are very expensiveImmunological methods Picture: A commercial enzyme immunoassay for rotavirus. The grey cross indicates a positive result. Image from Bufton A, ABBOTT Laboratories Ltd. Kits are now commercially available to diagnose infection with several pathogens, such as: · rotavirus (see picture) · Giardia lambliaWhich tests are performed? Where laboratory diagnosis is available, appropriate tests are selected based on the: · history · clinical features · stool examination· local diarrhoea epidemiology Image references ################ .\IMAGES\T33962.jpg .\IMAGES\T45388p.jpg The Role of Diagnostic Investigations: Assessment Are the following statements true or false? Click on the True or False button for each statement. Culture of a bacterial pathogen from a stool sample:To return to the start of the section. 1. is an easy and reliable investigation2. may be necessary for persistent diarrhoea3. takes longer than stool microscopy for PMNs4. is necessary if antibiotic sensitivity is to be determined Correct Text explaining the answer (11-pt plain blue) Incorrect Culture of pathogens in selective media is: · very labour intensive and expensive · not necessarily reliableIncorrect Text explaining the answer (11-pt plain blue) Correct Culture of pathogens in selective media is: · very labour intensive and expensive · not necessarily reliableCorrect In a child with persistent diarrhoea: · it is more important to try to identify the enteric infection, so that it can be treated · any delay introduced by culture may be less important than in acute diarrhoeaIncorrect Text explaining the answer (11-pt plain blue) Incorrect In a child with persistent diarrhoea: · it is more important to try to identify the enteric infection, so that it can be treated · any delay introduced by culture may be less important than in acute diarrhoeaCorrect Text explaining the answer (11-pt plain blue) Correct The timescales for these investigations are: · 2 - 3 days for culture· a few minutes for microscopyIncorrect Text explaining the answer (11-pt plain blue) Incorrect The timescales for these investigations are: · 2 - 3 days for culture· a few minutes for microscopyCorrect Text explaining the answer (11-pt plain blue) Correct Determination of antibiotic sensitivity: · is performed at a reference laboratory · requires culture of the bacterium Incorrect Text 11 pt Arial dark blue goes here Incorrect Determination of antibiotic sensitivity: · is performed at a reference laboratory · requires culture of the bacterium Correct Text 11 pt Arial dark blue goes hereImage references ################ Tutorial Assessment - 1 A 12-month-old girl is brought to the clinic by her mother because of diarrhoea. The questions you ask are listed below. Click on each question for the mother's reply. From the mother’s replies, what type of diarrhoea does the girl have? For the answer. How long has she had diarrhoea? Has she vomited during the illness? Have you seen any blood in the stools? Has she had a fever? What food has she had since the diarrhoea started? What fluids has she had since the diarrhoea started? Has she taken any medicine? Has she been immmunized against measles? Answer: Type of diarrhoeaThe clinical type of diarrhoea is: · acute - duration less than 14 days · watery - no blood in the stools Four or five days. Yes, in the first 2 days. No. Yes, I think so. A little boiled rice. Breast milk and some sweet tea. A preparation from the village healer. I’m not sure.Image references ################ .\IMAGES\Mumbub1.gif Tutorial Assessment - 2 You begin a physical examination of the child. What are the most important signs and what are you looking for? For the answer.To return to the start of the tutorial.Answer: Important signs You must look for signs of: · dehydration- assessed according to the WHO chart · malnutrition - especially for signs of marasmus or kwashiorkor · concurrent illness, eg. acute respiratory infection and measles Image references ################ .\IMAGES\Mumbub3.gif Tutorial Assessment - 3 You examine the child. She is irritable and crying, but you see no tears. Her eyes appear sunken, and her mouth and tongue are dry. She drinks eagerly from a cup, crying when it is taken away. Her skin pinch flattens quickly. Moving down through theWHO chart, select one category for each sign by clicking with your mouse. Then click your chosen degree of dehydration. To return to the start of the tutorial.1. Look at: Condition Well, alert Restless,Lethargic orirritable unconscious; floppy Eyes Normal Sunken Very sunken and dry Tears Present Absent Absent Mouth & tongue Moist Dry Very dry Thirst Normal, not thirsty Thirsty, drinksDrinks poorly eagerly or cannot drink 2. Feel: skin pinch Returns quickly Returns slowly Returns very slowly 3. Decide NO SIGNSIf two or moreIf two or more OFsigns, includingsigns, including DEHYDRATION one sign, SOMEone sign, SEVERE DEHYDRATION DEHYDRATION 4. Treat Plan A Weigh if possible,Weigh the patient, then Plan B then Plan CURGENTLYIncorrect The correct selection of signs is now shown on the chart in red. How many did you get right? Because the child has two key signs in the second column, she has some dehydration (treatment plan B). Correct The correct selection of signs is now shown on the chart in red. How many did you get right? Because the child has two key signs in the second column, she has some dehydration (treatment plan B). Incorrect The correct selection of signs is now shown on the chart in red. How many did you get right? Because the child has two key signs in the second column, she has some dehydration (treatment plan B).Image references ################ .\IMAGES\Patmgt.gif Summary Click on the buttons below for summary information. Picture: Severe dehydration - note the reduced consciousness, poor skin turgor and sunken eyes. Objectives of Clinical AssessmentDegree of DehydrationClinical Type of DiarrhoeaNutritional Status and Feeding PracticesConcurrent Illness andImmunization StatusThe Role of Diagnostic Investigations Copyright Image from International Centre for DiarrhoealDisease Research, Bangladesh. Objectives of Clinical Assessment Clinical assessment of a child with diarrhoea aims to: · determine the degree of dehydration · diagnose the clinical type of diarrhoea· assess the nutritional status and evaluate feeding practices · diagnose any concurrent illness · determine the immunization status, especially with regard to measles An appropriate course of treatment is then selected.Degree of DehydrationCareful physical examination should be carried out according to the WHO chart ‘Management of the Patient with Diarrhoea’. Other signs may also be helpful.Degree of dehydration Fluid deficitTreatment plan No signs< 50 ml/kgA. Home therapy to of dehydration preventdehydration andmalnutrition Some50 - 100 ml/kgB. Oral rehydrationdehydrationtreatment with ORS Severe> 100 ml/kgC. Urgent intravenousdehydration rehydration Clinical Type of DiarrhoeaClinical typeDefinition from history and stoolexamination Acute wateryLoose or watery stools without visible blood diarrhoea Duration less than 14 days Acute bloodyLoose or watery stools with visible red diarrhoea bloodDuration less than 14 daysPersistentLoose or watery stools with or without diarrhoea visible blood Duration 14 days or moreNutritional Status and Feeding PracticesA history should establish feeding practices from the mother. Nutritional status is based on physical examination for signs of: · severe malnutrition: - marasmus - kwashiorkor - marasmic kwashiorkor · vitamin (eg. vitamin A) deficiency · growth faltering, eg. use of growth chartsConcurrent Illness & Immmunization StatusThe most common serious illnesses in children under 5 years in developing countries are: · acute respiratory infection, eg. pneumonia· malnutrition · diarrhoea · malaria · measles The clinical history should establish whether the child has had any immunization, especially measles vaccine.The Role of Diagnostic Investigations Laboratory diagnosis has only a limited role in the management of diarrhoea. Diagnosis of the pathogen causing the diarrhoea: · is not usually necessary for management · may take several days · often requires resources that are not available Laboratory diagnosis may be required for: · persistent diarrhoea · determination of antibiotic sensitivity· epidemiological surveillanceSection 1 Section 2 Section 3 Section 4 jpg image goes here Copyright Copyright Image from ....... (copyright info) (10 point Arial, blue) Section 1 Pop-up text is in blue with a yellow title in 10 pt bold left aligned.The pop up is a display icon within the library, and if the text is too long then a scroll bar should be used, pop-up boxes can be larger. Section 2 Pop-up text is in blue with a yellow title in 10 pt bold left aligned.The pop up is a display icon within the library, and if the text is too long then a scroll bar should be used, pop-up boxes can be larger. Section 3 Pop-up text is in blue with a yellow title in 10 pt bold left aligned.The pop up is a display icon within the library, and if the text is too long then a scroll bar should be used, pop-up boxes can be larger. Section 4 Pop-up text is in blue with a yellow title in 10 pt bold left aligned.The pop up is a display icon within the library, and if the text is too long then a scroll bar should be used, pop-up boxes can be larger.Image references ################ .\IMAGES\T45895s.jpg You have now finished the tutorial Clinical Assessmentã The Trustee of the Wellcome Trust, 1998 Further reading Further activities Restart tutorial Picture: Oral rehydration therapy being given to a young woman with dehydration in Bangladesh.Copyright Image from Cutting WAM. Further reading Battacharya SK. Management of acute diarrhoea. Indian J Med Res 1996;104:96-102. Duggan C, Refat M, Hashem M, Wolff M, Fayad I, Santosham M. How valid are the clinical signs of dehydration? J Pediatr Gastroenterol Nutr 1996;22:56-61. King FS, Burgess A. Nutrition for developing countries. 2nd ed. Oxford: OUP, 1993. Richards L, Claeson M, Pierce NF. Management of acute diarrhea in children: lessons learned. Pediatr Infect Dis J 1993;12:5-9. World Health Organization. The treatment of diarrhoea - a manual for physicians and other senior health workers. WHO/CDR/95.3. Geneva: WHO, 1995.Further activities To look at pictures related to this tutorial, search the image collection using the following keywords: · diagnosis - clinical diagnosis · clinical features - dehydration · clinical features - type of diarrhoea · clinical features - malnutrition Image references ################ .\IMAGES\T44898.jpg