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Dr.

Faiza Siddiqui
FCPS Part II Trainee Dr. Ziauddin Hospital

BIO DATA: Name: Priya Fathers Name: Muhammed Shoaib Age: 13 Years Gender: female Day of admission: 2nd ,june, 2013 Mode of Admission: ER Religion: Islam Address: Nazimabad, Karachi

Vomiting (6-7 Days) Pale (4-5 Days) General weakness & fatigue (3-4 Days)

HISTORY OF PRESENTING COMPLAINTS


She had vomiting 4-5 episodes /day, after taking food, small in quantity, contains food particles, non projectile,non billious, non bloody. After 1-2 days of vomiting mother noticed that girl looking pale and she feels nausea for whole day. She got weakness & fatigue associated with dizziness and feel numbness in lower limbs. Taking less interest in daily activities.

PAST MEDICAL HISTORY; Not significant , no history of hospital admission or any illness. No any history of bleeding from mouth or in stool. PAST SURGICAL HISTORY: Not significant. No history of blood transfusion.

ANTENATAL Mother was taking routine antenatal checkups, and ultrasounds, took iron and folicacid supplements, and inj.tetanus toxoids. All 3 trimesters was uneventful. NATAL , Full term pregnancy delivered by spontaneous vaginal delivery at hosp. with 3 kg wt. POST NATAL No cyanosis, cried immediately and due to NNJ baby took in NICU for 24 hrs under observation then discharged.

FAMILY HISTORY:

.
4 Years 3 Months

. No Family history of any disease or any abnormality. Sibling is healthy and normal.

Prelacteal feed GHUTTI was given after 24 hours of life. She was on exclusively breast feed till 8th month of life.

Weaning started at 8th month of age with suji, cereals, khichri, roti. 5-6 times/day.
Now she takes only vegetables & fruits, and half glass of buffalo milk, she dont like to eat meat, mince or chicken, butter or cheese.

She was a student of class 7th, average student of her class, took less interest in extra cerricular activities.

PERSONAL HISTORY
Sleep; normal Apetite; normal stools Micturation; normal Bowel habbits; on&off soft &hard

BCG scar was present. She was fully vacinated according to EPI schedule. DEVELOPEMENTAL HISTORY Developmental milestones normally achieved at time. DRUG HISTORY Not significant.

7 family members living in a house. 5 well-ventilated rooms. Father was only earner of family. Use boiled water for drinking purpose. Overall socioeconomic history is good.

GENERAL PHYSICAL EXAMINATION

Girl was concious, well oriented with time, person and place. Lookind pale and lethargic.
WEIGHT; 49 kg VITALS R/R: 35 b/min HR: 98 b/min O2 sat: 97 % HEIGHT; 140 cm 99F 104/69 mmHg

Temp: BP:

SUB-VITALS Pallor, Mild dehydrated with no cynosis, clubbing, Jaundice, koilonychea,lymph nodes and Edema.

Head: size is normal in size and shape Face: No dysmorphic features

Oral Cavity: No evidence of oral thrush/abnormalities


Eye: Normal Ear: Normal Upper Limbs: Normal Lower Limbs: Normal

Central Nervous System:


Higher Mental Functions: GCS= 15/15

Motor System:
Soft Muscles Tone: Bilaterally normal in both upper and lower limb. Power: 5/5. Reflexes:
Normal knee jerk, ankle jerk. Planter Reflex downgoing.

Respiratory System:
Inspection: Shape of chest is normal, no any scar, moving equally with respiration. Palpation: trachea is centrally placed, apex beat is over 4th intercostal space on left side at midclavicular line. Percussion; normal in both sides.

Auscultation:

Bronchial breathing Bilateral equal air entry with no addd sounds.

Cardiovascular System:
Inspection: Symmetrical chest, with no abnormal bulging, moving symmetrically with respiration. No scar marks. No visible veins or pulsation. Palpation: No tenderness. No thrill or heave present. Apex beat in the 4th Intercoastal space, mid-clavicular line. Auscultation: S1 + S2 audible with no added heart sound

Abdominal Examination:
Inspection: Normal shape, depressed addomen. Moving symmetrically with respiration Umbilicus centrally placed Palpation: Soft, non-tender abdomen, no viceromegaly.
Percussion: Fluid thrill: Negative Shifting dullness: Negative

Iron deficiency Anemia Nutritional deficiency Anemia Thalasemia Hemolytic Anemia

CBC:
Date Hb PCV MCV MCH 02-06-2013 6.3 19 114 38 03-06-2013 6.0 18 05-06-2013 6.4 20

MCHC
NRBC Platelets TLC Neutrophil Lymphocyt e Monocytes Eosinophils

33
14/100 WBC <75 8.6 47 39 08 06 17/100 WBC 113 6.9 37 50 04 07 5/100 WBC 79 4.5 27 51 11 11

ESR: 15 Red Cell Count: 1.6 Microcytic, hypochro mic anemia

Iron Profile
Iron : 24 mg/dl TIBC : 309 g/dl Ferritin : 124 ng/dl % Saturation : 7.8 %

Folic Acid : 57.61 ng/ml (3-17 ng/ml) Vitamin B12 : <100 pg/ml () Vitamin D : 10.6 ng/ml MP : -ve Stool for Occult Blood : -ve

Urine D/R
Color : Yellow, slight turbit pH : 6.5 Sp. Gravity : 1.015 Blood : Trace RBC : 10 Leukocytes : 5 Bacteria : Few

Urine C/S