Doc-20240721-Wa0020. 20240825 163940 0000

Presentation 24/8/2024
peadiatric case
Prepared by
Abdisamad Mohamed Abdi
Personal
data:
⚬Name: Hussain muhudin
maow
⚬Age: 1 yrs
⚬Sex: Male
⚬D.O.A: 20/8/2024
⚬Residence: Madiino
⚬Informant (parent): sahro
Chief Compliant
Patient has been feeling
weakness for a week and a
cough for 3 days.
History of patient illness
Patient's weakness has gradually
increased with no specific time when
it occurs. The patient is less happy
and not playing as usual. The cough
is dry and continuous but gets better
with honey and black seed oil.
Systems review
skin : does not any rashes, bruising, nails,
and nail or hair changes
ear: no Ear discharge and Earache
nose: no Stuffy or running nose and Sore
throat. Throat: no Pharyngitis and Otitis
media.
EYES : pale colour
CVS : have techycardia , no shortness of
breath and no chest pain/palpitations
Continio...
RESPIRATORY : have dry cough.
GASTROINTESTINAL SYSTEM : (no abdominal
pain, no vomiting, no jaundice, no
diarrhea/constipation, no abdominal distention
& blood in stools).
CNS : (no fits, no syncope/dizziness, no
headache, no numbness/unpleasant sensations,
no weakness/paralysis, no frequent falls,
incontinence).
GENITOURINARY SYSTEM : no oliguria no
congenital anomalies of penis, testis or labia
and clitoris
Past medical history
He has been hospitalized before
and experienced vomiting for 2
days. There is no similar condition
he has experienced before. He
does not have any chronic
illnesses, and there have been no
previous surgeries.
Birth history
Antenatal history
Her health and nutrition were good
during pregnancy. She had a UTI
infection during pregnancy. She took
medication, and there were no
illnesses. She received all TT vaccines.
Her previous child was a miscarriage.
She started taking a contraceptive pill 7
months after having two miscarriages.
She stopped taking the pill after 4
months of use. She took the pill twice a
day, in the morning and at night.
Natal history
The birth took place at Hospital Yardımeli
after 9 months and 10 days. The doctor
had to perform a C-section due to twins,
which ruptured the amniotic sac. There
were complications, including blood loss.
She received 3 units of blood. The
pregnancy lasted a normal amount of
time."
Postnatal history
The baby cried immediately after birth.
There were no immediate problems or
complications.
Nutritional history
After the baby was born, the first thing
he was given was filtered water. Hours
later, he was breastfed. The mother told
us Six days after he was born, she
started giving him formula milk. After 6
months, she started introducing solid
food. The twin was eating the food, but
this baby refused to eat solid food. Until
now, he has only been given milk. His
twin started walking, but this baby has
not started walking yet. He also doesn't
seem happy or playful.
Family history
The family has no history
of hereditary diseases,
infectious diseases,
inbreeding, or similar
conditions in the child.
Immunization history
Patient mother
She administered all the mother's
immunizations.
The patient
She told us; she is waiting
the 1 yrs and half
vaccine.
Note: the mother told us that she don't
carry the immunization card the time
we take medical history
Growth history
Hight: 75cm
Weight: 9.2Kg
Socio-economics status
She told me that their lifestyle is
normal, and that they are
uneducated people from the
countryside. She also said that
their living conditions are good,
they don't have any animals in
their house, and they live alone in
the house.
General Examination
As we observed the child’s facial expression
was good.
During the first minutes of the visit the child
was not comfortable.
The child did not appear chronically ill but
seemed malnourished.
The child was dehydrated but there were no
signs of shock.
PHYSICAL EXAMINATION
The person's skin, especially on
their feet and hands, looked
pale.
HEART Tachycardia
ABDOMINAL Soft
PULMO Clear
NEUROLOGY Lethargy
On Laboratory
• CBC
• WBC 17.35, LYM 68.24, MON 7.32 ,
NEU 23.21, EOS 10.12, BASO 1.21
• RBC 4.32,
• HGB 4.6,
• HCT 18.3,
• MCV 42.5,
• MCH 10.6
• PLT: 318
DIFFERENTIAL
DIAGNOSIS
• Iron deficiency
8
anemia
•• thalassemia
Pneumonia
• Hereditary spherocytosis
Diagnosis
• Iron deficiency
anemia
Thank
You

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Presentation 24/8/2024

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