GULU UNIVERSITY MEDICAL JOURNAL

Gulu University Medical Journal (GUMJ) 2009/2010 Vol 5.
PART 1
Lamunu a one year old Acholi female toddler from
Amuru district Northern Uganda was brought into
Dr Doreen’s office by her mother who reported history
of (h/o) difficulty in breathing (DIB) for 4 days and
fever and cough for 3days. Although these were about
the only statements she could articulate in English, she
resented Dr. Doreen’s suggestion to use an interpreter.
“English no problem to me!” She exclaimed. History
taking was technical but Dr. Doreen gathered that the
patient was not growing as the mother expected and is
always crying in addition to the DIB, fever and cough.
The DIB was moderate, of sudden onset, constant
throughout the day, aggravated by attempt to play,
move around, lying flat or breastfeed with history of
gasping for air when breastfeeding and mildly relieved
by rest. It was associated with fast breathing but not
noisy. A day later she developed a dry cough which was
of sudden onset with no aggravating or relieving factors.
There is no known h/o TB contact or anyone at home
coughing. There is history of easy tiring while moving
around and breast feeding, however, no reported body
swelling. She developed a low grade fever too which
was of sudden onset, intermittent, relieved by tepid
sponging with no aggravating factors but associated
chills however, no convulsions, loss of consciousness or
vomiting.
Questions
1. Is it possible for Dr Dorine to come up with a
diagnosis at this point? Which ones could you
think of?
2. Support your answer.
PART 2
There was no significant finding on review of other
systems.
This is the child’s third admission. Index admission
was at 2 months of age at a private clinic with similar
symptoms. With a provisional diagnosis of pneumonia,
she received O2 therapy and other unspecified
medication on which she slightly improved 2 days
later, however, had regular visits to various clinics
Gumj Quiz
with similar symptoms. The second admission was 4
months ago at a referral hospital. Mother says she was
told, her daughter has a “hole in the heart” though she
had no medical documents to support this. She is too
concerned about her child’s unchanging health because
during her last visit to the hospital the Dr informed
her, the “hole” would close on its own. The infant has
frequently been on unknown medication, however,
with no h/o drug or food allergies and is of unknown
HIV sero status. She has not been diagnosed with any
chronic diseases like sickle cell disease.
She was transfused with half a unit of blood during the
last admission but no h/o surgical operations.
In the prenatal, natal and neonatal history, mother
conceived at 20years old, had 4 Antenatal Care visits,
was screened for syphilis and HIV infection (results not
given), and received folic acid tablets but not malaria
prophylaxis. She reports no h/o febrile illness, rash-like
illness, smoking cigarettes, taking alcohol, other drugs
of abuse or unprescribed drugs during the pregnancy.
She has never been diagnosed with any chronic disease
like Diabetes Mellitus (DM) or Hypertension (HT).
Labor lasted 6hrs, membranes ruptured spontaneously
and delivery was preterm (7 months) at home, by
spontaneous vertex delivery (SVD), assisted by a
traditional birth attendant (TBA). The cord was cut
with a razor blade from a nearby shop and tired with
pieces of thread from a clean cloth.
Child cried immediately and the weight taken 2 days
later was 2.2kg. No history of yellowing of body or
eyes or any admissions during the first 28 days of life.
Mother says the child has lost weight. She was
breastfed exclusively for 5mo. Breastfeeding (B/F) was
on demand though her poor health would frequently
interfere with desire to B/F. Complementary feeds
were introduced at 5mo due to insufficient breast milk.
They comprised of bean and fish soup with smashed
Irish potatoes. Currently she takes both breast milk
and complementary feeds including millet porridge
with milk, green vegetables, simsim, beans and sweet
potatoes. Meals are thrice a day prepared by mother or
siblings and eats about a handful.
The child received BCG (scar was observed) 2 days
after birth, but schedule was completed.
Growth and development had a slow progress. She can
laugh, bubble and make unspecific noises. She doesn’t
Gulu University Medical Students’ Association (GUMSA) Passion for life 59