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    Nutritional Assessment FINAL 3

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    Ananya Shee

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    Nutritional Assessment FINAL 3

    Uploaded by

    Ananya Shee
    7 views3 pages

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    Nutritional assessment FINAL 3

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    7 views3 pages

    Nutritional Assessment FINAL 3

    Uploaded by

    Ananya Shee

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    NUTRITIONAL ASSESSMENT

     Date : 25/06/2022
     Time : 11.00 am
     Place : Pediatric Medicine Ward of R G Kar MCH

    1. Identification Data

     Registration No. : RGK2200437620


     Name of the child : Farhina Khatun
     Age : 01 year and 05 months
     Sex : Girl
     Date of admission : 15/06/2022 at 12.48 pm
     Unit : IIIA
     Under Dr. : Dr. S. Som
     Provisional Diagnosis : Septic arthritis
     Address : Kathur, Basirhat, 24 PGS(N).
     Fathers name : Omar Faruk Gazi
     Informant’s name : Jesmina Bibi
     Relationship with the child : Mother
     Date of surgery : 16/06/22
     Name of surgery : Right knee joint arthrotomy done under GA

    2. Chief complain : Swelling of right knee and thigh since last 15 days.
    3. History of present illness : The child was developed swelling of right knee, insidious is
    onset, gradually progressive, extending proximally towards
    thigh. The child feeling tender along with local rise of
    temperature but no fever. Baby was unable to move right lower
    limb.
    4. Past history of illness : Nothing Significant
    5. Birth history
     Type of Delivery : Term baby delivered by LUCS.
     Any complication during birth : No any complication was arisen during delivery and postnatal
    Period.
    6. Immunization History : All vaccines are Completed according to age.
    7. Socioeconomic History-
     Residence : Municipality area
     Housing type : Pacca
     Family income : Rs. 12000 /months
     No of family members :4
     Recreational facility : Television, Cell phone

    8. Dietary history-
     Duration of breast feeding : Till now continue
     Age of weaning : 6 months
     Dietary pattern : Nonvegetarian
     No of meals per day : 6 times
     Feeding problem (if any) : No any problem

    9. Personal History
     Personal hygiene : Clean
     Sleep Pattern : Good
     Elimination habit : Regular
     Exercise/play/ hobbies : Play with play material, sometimes play with own.
     Relationship with other : Good

    10. Anthropometric method/ measurements-

     Height (Cm) : 62 cm
     Weight (Kg) : 3.22 kg
     Head circumference : 39 cm
     Chest circumference : 39 cm
     Mid upper arm circumference : 10 cm
     BMI : 8.47

    11. Biochemical Methods/ measurements

     Hemoglobin : 11gm/dl
     Stool examination : Not Available
     Urine examination : No growth of organism in urine culture. There are
    albumin and sugar not Present.
     Blood examination : PCV-35.7, WBC- 16,200, Urea-17 gm/dl, creatinin-0.6gm/dl,
    Na- 139, K+- 5.8, Total protein- 6.1, Albumin - 3.2, Bilirubin-
    0.4
     USG : Not done.
     Examination of synovial fluid : Growth of staphylococcus aureus.

    12. Clinical methods/ assessment

     General appearance : Normal built /Thin / sicky


     Hair : Normal / lack of luster/ dyspigmented/ thin and sparse/ easy
    Pluckable / flag sign
     Face : Normal/Diffuse depigmentation / nasolabial /dyssebacea/ moon face
     Eyes
     Conjunctiva : Normal / dry on exposure for ½ min / dry and wrinkled / bitot’s
    spots/ brown pigmentation / angular pale conjunctiva.

     Cornea : Normal / dryness / hazy or opaque.

     Lips : Normal / angular stomatitis / cheilosis


     Tongue : Normal / pale and flabby / red and raw/ fissured / geographic
     Teeth : Mottled enamel / caries / attrition
     Gums : Normal / spongy bleeding
     Glands : Thyroid enlargement / Parathyroid enlargement: Not Present
     Skin : Normal / dry and scaly / follicular / hyperkeratosis/ petechiae /
    Pallor / dermatosis /scrotal and vulval dermatosis
     Nails : Normal / Koilonychia
     Edema : Not Present
     Rachitic changes : Knock- knee or bow legs / epiphyseal enlargement / beading of
    Ribs / pigeon chest: Not Present
     Internal systems : Hepatomegaly / psychomotor changes / mental confusion /
    sensory loss / muscle wasting / motor weakness / loss of ankle and
    knee jerk / tachycardia: Not Present

    13. Impressions / Remarks-:


    No any nutritional problem seen in children but physical growth and developmental milestone are
    not achieved according to age. Mother is advised to give adequate nutritious homemade diet, plenty
    of water to the child, maintenance of hygiene, prevention of infection and regular checkup.

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