✅ Model Answer:
• Diagnosis: Kwashiorkor (protein-energy malnutrition) – generalized edema, skin desquamation (flaky paint dermatosis), reddish-brown hair (flag sign), apathy, hypoalbuminemia (1.6 g/dL), total protein low (3.5 g/dL), no proteinuria, normal liver function. Adequate caloric intake but deficient protein intake.
• Any other test: Micronutrient levels (zinc, iron, vitamin A, B12, folate), blood culture (sepsis risk), stool for ova/cysts, HIV test, TB screen, 24-hour urine protein (exclude nephrotic syndrome).
• What to do next: Gradual nutritional rehabilitation: start with F-75 (low calorie, high protein) then F-100. Treat infections (broad-spectrum antibiotics). Vitamin A supplementation (100,000-200,000 IU). Monitor for refeeding syndrome (hypophosphatemia, hypokalemia, hypoglycemia).
• Follow-up plan: Daily weight, edema chart, monitor electrolytes, phosphorus. Gradual increase in calories. Long-term: nutritional education, food security, follow-up for growth and development.

✅ Model Answer:
• Kwashiorkor: Protein-energy malnutrition characterized by edema, hypoalbuminemia, skin changes, hair changes, and apathy. Caused by protein deficiency with adequate caloric intake.
• Marasmus: Protein-energy malnutrition characterized by wasting, severe weight loss, muscle atrophy, no edema. Caused by caloric deficiency (inadequate total energy intake).
• Key differences:
- Edema: Present in Kwashiorkor, absent in Marasmus
- Weight: May be normal or low in Kwashiorkor; severely low in Marasmus
- Skin/hair: Skin desquamation, hair discoloration in Kwashiorkor; normal in Marasmus
- Appetite: Poor in Kwashiorkor; ravenous in Marasmus
- Albumin: Very low in Kwashiorkor; low-normal in Marasmus

✅ Model Answer:
• Edema: Generalized pitting edema (pedal, periorbital, genital, ascites)
• Skin changes: "Flaky paint" dermatosis (hyperpigmentation with desquamation), fissuring, ulceration
• Hair changes: "Flag sign" (reddish-brown discoloration), sparse, brittle hair
• Moon facies: Round, swollen face
• Growth: Poor weight gain, may be underweight or normal weight
• Behavior: Apathy, irritability, listlessness
• Other: Hepatomegaly (fatty liver), abdominal distension, diarrhea, muscle wasting

✅ Model Answer:
• Pathophysiology:
- Protein deficiency → decreased hepatic synthesis of albumin → hypoalbuminemia
- Hypoalbuminemia → decreased plasma oncotic pressure → fluid shifts from intravascular to interstitial space → edema
- Impaired immune function: decreased immunoglobulins → increased susceptibility to infections
- Fatty liver: Decreased lipoprotein synthesis → fat accumulation in the liver → hepatomegaly
- Skin and hair changes: Protein deficiency affects keratin synthesis → skin desquamation, hair discoloration
- Anemia: Iron, folate, B12 deficiency

✅ Model Answer:
• WHO guidelines for severe acute malnutrition:
- Phase 1 (Stabilization): F-75 formula (75 kcal/100 mL, 0.9g protein/100 mL) – 130 mL/kg/day
- Goal: Stabilize the child, correct fluid/electrolyte imbalance
- Treat infections: Broad-spectrum antibiotics (ampicillin + gentamicin)
- Vitamin A: 100,000 IU (if 6-12 months) or 200,000 IU (if >12 months)
- Folic acid: 1 mg/day
- Zinc: 20 mg/day
- Iron: Start after appetite returns (3 mg/kg/day)
- Monitor: Weight, edema, electrolytes, blood glucose
- Avoid: Rapid weight gain (refeeding syndrome)

✅ Model Answer:
• Phase 2 (Rehabilitation):
- F-100 formula: 100 kcal/100 mL, 2.9g protein/100 mL
- Transition from F-75 to F-100 when edema resolves and appetite returns
- Target: 15-20 g/kg/day weight gain
- Duration: 1-2 weeks
- Oral rehydration: Continue fluids
- Micronutrients: Continue vitamin A, zinc, folic acid; start iron
- Ready-to-Use Therapeutic Food (RUTF): Plumpy'Nut – can be used in community settings
- Monitor: Weight gain, edema resolution, appetite

✅ Model Answer:
• Complications:
- Refeeding syndrome: Hypophosphatemia, hypokalemia, hypoglycemia (due to rapid carbohydrate feeding)
- Infections: Sepsis, pneumonia, UTI, gastroenteritis (due to immunodeficiency)
- Electrolyte imbalances: Hypokalemia, hyponatremia, hypocalcemia
- Heart failure: Due to fluid overload (edema, anemia)
- Hypoglycemia: Due to depleted glycogen stores
- Thrombosis: Due to hypercoagulability
- Death: If untreated, mortality rate up to 30-40%
- Long-term: Growth failure, cognitive impairment, osteoporosis

✅ Model Answer:
• Prognosis:
- Acute: Excellent with prompt nutritional rehabilitation (mortality <5% with proper treatment)
- Long-term: Good but may have persistent growth failure or cognitive impairment
• Factors affecting prognosis:
- Age: Younger children (<2 years) have worse outcomes
- Severity: Degree of edema, hypoalbuminemia, infections
- Complications: Presence of refeeding syndrome, sepsis
- Social factors: Poverty, food insecurity, caregiver education
• Long-term outcomes:
- Catch-up growth: Possible with adequate nutrition, but may not reach full genetic potential
- Cognitive: May have learning difficulties, memory impairment
- Recovery: Skin and hair changes resolve with nutritional rehabilitation
- Relapse: Risk if food insecurity persists
- Prevention: Nutritional education, food security, micronutrient supplementation