MULAGO HOSPITAL

INTERNATIONAL HEALTH SCIENCES UNIVERSITY

FACULTY OF NURSING
Case Report # 2

Student's Name: Joseph Kalibbala

Registration No: 2008 – BNS – FT – 009

Name: NJ
Age: 11/12
Sex: Female
Address: Mulago
Religion:Roman Catholic
Tribe: Musoga
Informant (NOK): AK
Relationship: Mother
Referral: None
Date for registration: 24th . 11. 2010
Registration Number: 30372/10
Ward: Acute Care Unit

Transfered to ward 16

Presenting complaint
 Fever
 Convulsions

History of presenting complaint

The child was well until one ago when she developed a high grade fever in the
evening, the mother reports that she tepid sponged the baby and also gave panadol
before they slept and this seemed to have reduced the temperature for a while. The
mother reports that in the night the fever rose yet again. Here she says she called up
the neighbors who gave the child garlic and another drug that was given per oral
which the mother described as “chloroquine”. After this she reports that she came to
Mulago hospital.

Past Histories

Antenatal Histories
The mother reports that she attended antenatal care and she started attending when
she was six months and attended four times. On the first day of antenatal care she
and others were given health talks about what they should come with when they are
going to deliver they babies. She also says that she received tetanus injection once
during the visits. She received medications like fansidar and folic acid during her visits
though she does not remember how many times she received them. She tested HIV
negative. She further more says she was not admitted during her pregnancy and her
pregnancy was full term.

Labor
The mother says that her labor was spontaneous and her labor pains started around
4am in the morning and she gave birth around 9am in the morning. Her labor lasted
6hours.

Delivery
She delivered from Mulago ward 14 on Sunday 13th . December.2009 by spontaneous
vaginal delivery, and the baby cried immediately. The baby weighed 2.5kg and the
baby had no birth injuries or abnormalities.

Post – natal History

The mother reports that, her and the child were discharged immediately and they were
not given any medications, even immunization, since it was a Sunday, thus they had
to come back on Tuesday the following week to get the doses received at birth.

Past Medical History

This is the child's index admission. The mother reports that her child has not had any
serious conditions apart from cough in the past of which it was treated with amoxycilin
and paracetamol. NJ is not a sickler, or asthmatic.

Past Surgical History

The child has not had any surgeries, fractures or any blood transfusions.

Family history
NJ is the second born. She has an older brother who is seven years old. They both
stay with there parents. They sleep in mosquito nets. The mother reports that there
are no family illness like sickle cells, asthma. The husband is alive.

Social History
The mother reports that she is married and staying with the husband who is an
engineer. The mother says that she does not work, she is a house wife.
The mother says that they access to a clean source of water and a toilet. They are no
bushes around the house.

Note: A Blood slide was done and no malaria parasites were found.

Current Medications
 IV Ceftiraxone 870mg OD *7/7
 IV Qnn 87mg in 180ml 5% DEX – 3 doses.
 Tabs Paracetamol 125mg TDS * 3/7
  IV 25% Dextrose

Immunization:
The mother reports that her child completed immunization course but does not have
the immunization card. Plus on asking more questions, she was not sure what was
given or not. BCG scar seen.
That Growth and Development:
The mother reports that her child has grown very fast. She says her child had a social
smile at 2 months, she started sitting at 4 months crawled at 5 months, and she can
now stand though with support.

Nutrition History
The mother says that she exclusively breast fed the baby on demand up 6 months.
Then she started introducing complementary feeds in two ratios, for example lunch
and in the evening. The complementary foods include Irish, an egg, milk (mashed
together).

Reviews of Systems:
CNS: The child is fully conscious and active.
CVS: There is no history of cardiovascular problems for example hypertension.
GIT: The child has been having a good appetite until she got ill. The child has no
difficulty in swallowing , no vomiting, no diarrhea.
GUT: NJ has normal micturation habits. No pain on passing urine. The mother reports
she changes the pampers 3 times in a day.
ENT: No history of ear discharge.
MSS: No history of joint pains. Normal muscle tone.
Reproductive: No swellings, discharges on the reproductive parts of the child.
Skin: No itching, rashes, scars or lesions.

Physical Examination:
Vitals
Temp: 36.8°C
Respiratory rate: 48bpm
Pulse rate: 101bpm

Growth measures:
MUPC:14cm
Head Circumference: 43cm
Chest circumference:43cm
Length: 71cm
Weight: 8.7kg
Generally the baby is well kept.

Hair
Well kept, soft, black, no dandruff or lice present. The hair is evenly distributed.
Nails
They have a normal curve, clean, pink and normal capillary refill of 2 seconds.
Scalp
No scars, of lesions.
Face
Symmetrical, no scars, masses or lesions.
Eyes
They two, symmetrical, no jaundice, no anemia, no discharge noted. Black Pupils. The
skin around the eyes is intact, eye brows and eye lashes are present.
Ears
They are two in number and symmetrical.
Nose
Two nostrils are present, and symmetrical. No discharge noted.
Mouth
Lips are the same color as the skin, they moist. The gum is pink, no teeth. The tongue
is pink. No anemia.
Neck
No lymph nodes felt, no scars, no swellings or lesions. No enlargement.
Thorax and chest
The chest is symmetrical, no scars, no swellings.
On auscultation pulsations are noted, presence of audible heart sounds.
Normal breath sounds are heard on auscultation.
Breast and axillae:
Two breast, skin color is uniform, no tenderness and masses noted. Round nipples.
Per Abdomen
No scars or lesions, no enlarged organs.
Normal fullness and shape of the abdomen. The skin is febrile on touch. No
dehydration noted.
On auscultation there are normal bowel sounds heard.
Musculoskeletal systems
Muscles in the arms and feet are equal in size. No deformities, swelling and scars.
CNS
The child was conscious.

Differential Diagnosis:
Malaria
Meningitis
Nursing concerns
High Temperature
Reduced Appetite
Risk of convulsions (seizure).