Most commonest type nutritional anaemia.pptx

One of the underestimated anaemia

1. CASE PRESENTATION

2. A 9 year old male child by name Raju , resident of Indrapalem , Kakinada was brought to the hospital by his mother who is tailor, who can read and write and her reliability of her information is good. . CHIEF COMPLAINT : - Decreased activity of playfulness since 1 month - shortness of breath on exersion since 15 days -Tingling and numbness since 10 days - Paleness of skin since 8 days

3. HISTORY OF PRESENT ILLNESS: According to the mother the child was apperently normal 1 month back , then he developed : - Decreased activity of playfulness Onset :Insidious Duration :1 month Progression: gradually progressed Associated with :Irritation - Shortness of breath Onset :Insidious Duration :15 days Progression :gradually from Grade 1 to grade 2 Relieved on:Taking rest -Tingling and numbness Onset :Insidious Duration :10 days Progression :gradually progressed initially Involving fingertips now progressed to hands

4. -Paleness of skin:
Onset: Insidious
Duration: 8 days
Progression: gradually progressed
Associated with: fatigue Not H/o fever and lymphadenopathy Not H/o nausea ,vomiting , malena , constipation, abdominal pain No H/O weight loss No h/o increased sensitivity to cold

5. System review CVS: No h/o chest pain, palpitations, cyanotic spells, no pedal edema Respiratory system: no h/o productive cough and wheezing, fever GIT: No h/o pica,melena , constipation , diarrhoea CNS: no signs of meningitis, no altered sensorium , no disturbance of sleep behavior and consciousness and paraesthesia of fingers present Musculoskeletal: no h/o joint pains Genito urinary: no h/o hematuria no h/o pain with micturition Hematological : H/o early fatigability [decreased duration of playfullness ] h/o dyspnea on exertion present Skin: pale skin, no rashes, no petethiae RES: no h/o bleeding gums

6. PAST HISTORY : No h/o similar complaints in the past No h/o tuberculosis, Bronchial asthma, Epilepsy, Jaundice No h/o repeated blood transfusions No h/o previous surgeries

7. PERINATAL HISTORY: ANTENATAL HISTORY: (obstetric formula – G2P1L2) Age of mother at conception:20 Regular antenatal checkups done IFA supplementation taken, 2 doses of TT taken No h/o TORCH infections No h/o radiation exposure, drug exposure No complications during pregnancy NATAL HISTORY: Term gestation Normal vaginal delivery at GGH, Kakinada Birth weight: 2.8kg Baby cried immediately after birth POSTNATAL HISTORY: No h/o neonatal jaundice, no h/o feeding difficulties

8. FAMILY HISTORY Non- consanguinous marriage No h/o similar complaints in the family No h/o TB contact and other infections

9. DEVELOPMENTAL HISTORY The child is studying in 4 th class. No developmental delay is seen.

10. IMMUNISATION HISTORY: 0 dose- bcg , opv , hep b taken 6,10,14 weeks - rota , penta , opv taken 6,14 weeks- ipv taken 9-12 months- MR1, jpe-1 taken 16-24 months-DPT1,MR2,OPV booster,JE2 taken 5-6 years- dpt 2 booster SOCIO-ECONOMIC HISTORY: Belong to class 4 according to modified Kuppuswamy SES scale

11. DIETARY HISTORY : The child is following strict vegetarian diet. Milk and milk products are also avoided.

12. GENERAL EXAMINATION : Conscious, coherent, co-operative Pallor: Present No signs of Icterus , cyanosis , clubbing , generalized lymphadenopathy , pedal edema VITAL DATA: Temperature: 98.4°F Pulse rate: 92beats/min, normal volume, no radio-radial and radio-femoral delay, peripheral pulses present Respiratory rate:18 breaths/min, abdomino -thoracic type Sp02: 93% at room air BP: 110/60mmHg in supine position, measured in left arm Capillary Refill Time: 4 sec

13. ANTHROPOMETRY MEASUREMENTS observed expected height 131cm weight 29kgs MUAC

14. HEAD TO TOE EXAMINTION : Head: shape and size are normal Eyes: eyelids, eyebrows, eyelashes are all normal. Nose: nose bridge and philtrum are normal. Mouth: Lips palel , buccal mucosa pale, tongue is beefy red. Neck: no swellings Upper and lower limbs normal Skin- hyperpigmentation of skin at knuckles mainly of interphalanges in the dorsum of hand. Genitalia - normal Spine - no deformity

15. Systemic examination Cns : Handedness:right Higher mental function, speech, cranial nerves, motor system :normal Reflexes, posture:normal Sensory examination : vibration and positional loss Spinal and cranial examination , extrapyramidal , cerebellar disease :normal Peripheral nerves examination :normal Examination of meninges :no signs of meningeal irritation that is neck stiffness, kerengs signs, brugisiki sign :normal

16. Other Systems Examination CVS- S1 and S2 are heard no added adventitious sounds No murmurs and thrills Respiratory- Trachea in midline Normal vesicular breath sounds Hematological- Signs of anemia seen at buccal mucosal, palpeable conjunctiva, red beefy tongue, hyperpigmentation of skin Lymphatic- No lymphedenopathy Per abdomen - Soft and non tender, No organomegaly , Bowel sounds present

17. Provisional diagnosis: A 9yr old male child raju came with chief complaint of decreased activity of playfulness, shortness of breath, tingling and numbness,anaemia probably a anaemia due to nutrional deficiency ( megaloblastic anemia )with no other complications.

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