This medical record is for a 7 month old male patient admitted for severe anemia. The patient fell and lost consciousness for 2 minutes. On examination, he was pale with a hemoglobin of 4.3 g/dL. Investigations showed severe reduction in red blood cells. He received 2 units of packed cell transfusion which improved his hemoglobin to 12 g/dL and was discharged on crushed food feeds. The differential diagnoses included G6PD deficiency, hemolytic disease of newborn, and anemia of prematurity.
This medical record is for a 7 month old male patient admitted for severe anemia. The patient fell and lost consciousness for 2 minutes. On examination, he was pale with a hemoglobin of 4.3 g/dL. Investigations showed severe reduction in red blood cells. He received 2 units of packed cell transfusion which improved his hemoglobin to 12 g/dL and was discharged on crushed food feeds. The differential diagnoses included G6PD deficiency, hemolytic disease of newborn, and anemia of prematurity.
This medical record is for a 7 month old male patient admitted for severe anemia. The patient fell and lost consciousness for 2 minutes. On examination, he was pale with a hemoglobin of 4.3 g/dL. Investigations showed severe reduction in red blood cells. He received 2 units of packed cell transfusion which improved his hemoglobin to 12 g/dL and was discharged on crushed food feeds. The differential diagnoses included G6PD deficiency, hemolytic disease of newborn, and anemia of prematurity.
This medical record is for a 7 month old male patient admitted for severe anemia. The patient fell and lost consciousness for 2 minutes. On examination, he was pale with a hemoglobin of 4.3 g/dL. Investigations showed severe reduction in red blood cells. He received 2 units of packed cell transfusion which improved his hemoglobin to 12 g/dL and was discharged on crushed food feeds. The differential diagnoses included G6PD deficiency, hemolytic disease of newborn, and anemia of prematurity.
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DATABASE
#1 VICHRAM S PAULRAJ MEDICAL STUDENT
Patients name : David Chacon
Patients Regn # : 15703 Sex : Male Age : 7/12 Race : Amerindian Address : NWD , Mabaruma Date of Admission : 16/08/2016 Admitting Dx : Severe Anemia for Investigation .
Chief Complaint C/O : Pt was referred from mabaruma hospital for management of Severe Anemia and 2 trauma to head and LOC.
History of Present Illness :
Infant 7 /12 the pts mother reffered he was with his dad on the chair who turned away for a second when the pt fell on the concrete floor facing his back , but mother not sure if he hit his head , but she mentioned the baby had LOC for 2 minutes , denies vomiting , bleeding and sezuires and when the pt was conscious she refeered he started to cry , in addition 3/52 persons said the baby was looking pale to her .
Birth Hx Maternal Hx : no Bleeding , No Trauma , No HTN , DM , Smoking , PROM + Gestational Age : 33 +6 Labour : LSCS ( water bag burst ) no fetal distress Neonatal Period : BW : 3.5 kg , cried immediately , Stayed in hospital for 1/52 for drinking dirty water and was under phototherapy for 2/7 Feeding Hx : Breast feed alone , tried crush porridge but baby not taking .
Devolopmental and Social Hx
Growth and Developmental Hx : Adequate for age Family Hx : DM Type 2 Grandmother Social Hx : Lives in concerete house , 3 bdroom with 5 occupants well build and sanitary conditions .
Physical Examination Temp : 37.1 C Pulse : 132 Weight : 7.5kg Resp : 36*1 Head : Normaocephalic with Positional Plagiocephaly , Normotensive , AF closed Eyes : Pale + Moist , Strabismus (-) , ENT : No nasal Flaring , No erythema , tonsils noted Neck : Normal , no lymphadenopathy Resp System : No nasal Flaring , BAE 2+ , No adventious sounds , No creps , No wheezes
ABD : Globulus , Non distended , Moves normal to resp
movements , BS + , Soft , Depressible No Oragnomegaly Genito Urinary : Normal , Male , No Hydrocoeles , Cryptorchidism Musculo skeletal : Pale looking , No lesion , No scars , Edema (-) , Clubbing (-) , Ortholani (-) Extremities : Normal * 4 , R foot IV access Nervous System : Concious , Active , Alert , Sucking + , Moro
Investigations Hb : 4.3 g/Dl PLT : 372 *10(9) WBC : 10.6 *10(9) Addn : Severe reduction in RBC , Microcytes + Malaria : - ve
Investigations
Investigations
Sodium : 138 mmol/L
148)
( 135-
Potassium : 4.4.7 mmol/L
(3.5-5.3 )
Treatment 17/08/2016
2 Units PC Transfusion Lasix IV 4 mg Post transfusion O/S F/U Stool , Hb , Malaria
