CLINICO-PATHOLOGICAL

CONFERENCE
INTEGRATIVE MEDICINE

ABERIN, ALEKZANDRA MITZI

CARAIG, JIANINA MARIE
DE CASTRO, FRANCINE ADRIENE
GALAMAY, MARY GRACE
MONDRAGON, NICOLA
GENERAL DATA
10 month olds
male
CHIEF COMPLAINT Pallor
Filipino
Jaundice
TEMPORAL Iglesia Ni Cristo
PROFILE Gross hematuria
Quezon City
NUTRITIONAL
HISTORY

NEURODEVELOPMENT
AL
 TEMPORAL PROFILE
UA
UA hematuria
Protenuira
Ketonuria
hematuria CBC=
normo,
normo
CBC anemia
STOOL Hgb 54
EXAM WBC 34.7
LABORATORY CXR Lym 51
unremarkab
le

Trad. Healer
MANAGEMEN Herbal ointment
T

PARACETAM Hosp- Pedia Hosp- Pedia

OL Dx URTI w/ Dx AGE w/
PHENYLPROP AGE no DHN Mod DHN
A- Pneumonia
NOLAMINE
SALBUTAMO
L N.
ORS
SALBUTAMO
L O.
AMPICILIN
SYMPTOMS
CEFUROXIME
RECECADOT
FEVER
RIL
COUGH &
COLDS
DIARRHEA
DEC.
APPETITE &
DEC.
ACTIVITY
PALLOR
JAUNDICE
GROSS
HEMATURIA 7 PTA 6 PTA 5 PTA 4 PTA 3 PTA 2 PTA 1 PTA AD
 Exclusively breastfed per
GENERAL DATA No delays
demand in terms of
until 6 months
motor, cognitive, social,
old
CHIEF COMPLAINT and language feeding
Complementary
development.
started at six months
TEMPORAL Social
old, smile
with at 2 months.
mashed fruits
PROFILE Headvegetables.
and control at 3 months
old. patient now
The
NUTRITIONAL Able to sit alone
consumes and
table food
HISTORY
babble rice
mainly at 6 with
months
soupold
NEURODEVELOPMENT Ablemeat,
and to walk with
with no food
AL assistance at present.
preference.
Patient is
currently
given is able to
 No history of
Patient lives with his parents
PAST MEDICAL HISTORY 1hospitalizations,
and dose of BCG
siblings in a well-lit and
3and
doses
well-ventilated of
surgeries. Hep B,
2-bedroom
IMMUNIZATION single detached house in QC
HISTORY DPT,
No known
Garbage HiB and
collected OPV
allergies
every day,
vaccines
tosegregated.
not food or
Drinking water is distilled, from
FAMILY HISTORY 1medications.
waterdose ofstation.
refilling measles
NoNewborn
exposure to smoking in the
vaccine
ENVIRONMENTAL household.
HISTORY No
screening
No untoward
nearby history
factories, or
was not
exposure to chemicals in the
reactionsor noted
environment
PHYSICAL EXAMINATION obtained.household.
 PHYSICAL EXAMINATION

Awake,
Heart:
Ears:
SKIN: (+)weak
hemic looking,
normal
Sallow murmur carried by the
Eyes: Pale palpebral
mother,
Abdomen:notFlat in distress
conjunctiva,
Nose: clear anicteric
nasal

sclerae,
watery
Genitals:
discharge
VITAL
due
NORMAL
no eyeBP:
SIGNS:
to increase
discharge
normal
80/50
NORMAL
bilirubin
Mouth HR:Pale,
& neck: 150 bpm
level in body caused by moist lips and buccal
Due toliver
mucosa
Extremities:
Hemolysis, Anemia
Pale palms
disease or and
Lungs: RR: 48 cpm
Occasional crackles bilateral
gallbladder
soles, No problem cyanosis
Neurologic Exam: Unremarkable
 LABORATORY RESULT

Hg
b
Hc
PLATELE Thromocyto
ANEMIA
tT sis
COUNT
RB
ormocytic
C Normochromic Anemi
Toxic granulations
Reticulocyte count: 1.2%
 NORMAL
COLOR to
URINALYSIS
Orange have
Red a low
10-6-16
outside
10-10-16
Light
outside
10-11-16

COLOR Orange Red

YellowLight Yellow

protein concentration or
TRANSPAREN
TRANSPARENCY
PH
Hazy
Hazy
6.0
Hazy
Hazy
8.5
Slightly
Slightly Hazy
8.0
CY Hazy
traces
EPITHELIA in
SPECIFIC

WBC
GRAVITY the urine
1.020
INCREASED
0-3
None None during
None
1.015

51
1.0002

BLOOD disease
L CELLS
GLUCOSE
Trace N
++
state.
CATABOLISM /
N
Modera N

RBC HEMOGLUBINUR
BILIRUBIN
BACTERIA2-4 None
N
0-1 2
te
Few
N
Occasiona
N

DEHYDRATION
PROTE
KETONE
+ +
++
CATABOLIC STATE
BLOOD TraceTrace
l
Trace
++
N
Moderate

IN INDICATES IAPRESENCE
HEMOGLUBINURIA
UROBILINOGEN
SECONDARY
Normal
TO
Normal Normal
NITRITE
&
Specimen N N N

OF INFECTION
KETON DISEASE
++
LEUCOCYTES
Trace
STATE
N
N N N

E RBCHEMOLYSIS
PROTEIN

collection
HEMOGLUBINU
+
2-4
+
0-1
Trace
2
WBC 0-3 None 5
EPITHELIAL None None 1
 Serum Reference
Chemistry135-
Range
10-6-16
(outside)
10-10-16
(outside)
137-
Reference
Range
10-10-16
(PCMC)
(outside)
148
15-37 133.4 145 133
Na
ASTAST 15-37 U/L 3030
mmol/
U/L (dec) mmol/ (dec)
313-
ALT
Total L12-78 U/L 35 L U/L 1325
21-72 9593 (inc)
LDH 12-78
0-17.1 618
21-72
3-22 1325
114
Bilirubi
ALTBilirubin 3.5-
Total 0-17.1
umol/L
3.11
35
3.11 3.5-
3-22
umol/L umol/L (inc)
114
(inc) (inc)
nDirect U/L
umol/L U/L
U/L (inc)
5.3 3.33 5.1 5.6
K
Direct mmol/
Bilirubin
Indirect
71-
0-5 INCREASED
0-5 umol/L
INCREASED
0-12.1 (dec)
0.52
DUE
0-3
TO
mmol/
0-3
umol/L
58- 52 (inc)
(inc)
Creatini
Bilirubi
n
Bilirubin L115
umol/L INCREASE
HEMOLYSIS
HEMOLYSISumol/
umol/L
0.522.59
73.80
0-19 110
L
umol/L
umol/L 52 62 21
(inc)
(inc)

ne umol/
71-115 58-110
(dec)
Creatinine
Indirec
L
INDICATES
STARVATION
umol/L
DUE L
73.80
umol/L
21 (dec)

HEMOLYSIS DUE TO
135-148 137-145
t Na 0-12.1 0-19
ELECTROLYTE
133.4 (dec) 133 (dec)
TO DEHYDRATION
mmol/L mmol/L
2.59 62 (inc)
Bilirubi umol/L
3.5-5.3 umol/L 3.5-5.1

BREAKDOWN OF
K 3.33 (dec) 5.6 (inc)
n
Cl
LOSSES DURING
mmol/L mmol/L
98-107
99
mmol/L
 LABORATORY RESULT

Urine Hemoglobin
CHEST XRAY
Date PAL10-11-16
10-6- To know the
10-13-16 causeS/SX
RELATED of
BLOOD CULTURE For possible
2016 Positive
Urine respiratory infection
Positive
10-10-2016
Hemoglobin causes of anemia GROSS
unremarkable (cough and colds)
HEMATURIA
NEGATIVE
ABDOMINAL To know other causes of
(Hemolysis,
ULTRASOUND 10-10- Normal stool
(from color.
parasitic,autoimmune)
diarrhea different
2016 Bloodorgans may in be
the due
GIT)
unremarkable to irritation of
lumen due to
 COURSE IN THE WARD

BLOOD CULTURE

URINE
MANAGEMEN
T&
HGB
LABORATORY NORMO, NORMO ANEMIA
DEC
INCHGB LFT
BILIRUBIN,
DEC NACL
ALT, LDH NEGATIVE
O2 2lpm,
HEMOGLOBINU BLOOD CULTURE
INC WBC, LYM 64
nasal RIA SERUM
IVF ELEC
PRBC
transfusion CBC
AMIKACIN RESOLVE CLARITHROMYCIN
CBCANEMIA ZINC SULFATE
PIPERACILIN
BACILUS
WBC INCREASED (41) FOLIC ACID
CLAUSI
ZINC S04
FOLIC ACID
VIT E

SYMPTOMS

FEVER
COUGH &
COLDS
DIARRHEA
APPETITE &
ACTIVITY
PALLOR
JAUNDICE
GROSS
HEMATURIA
WEAK
LOOKING 1ST HD 2ND HD 3RD HD DC FC
 MEDICATIONS
AMIKACIN (Aminoglycoside)
FOLIC ACID Treatment
Prevention and of treatment
serious ofgram-negative
bacillary infections
megaloblastic and infections
and macrocytic caused
anemias.
by staphylococci
Required when
for protein penicillin's
synthesis and or
redother
less
bloodtoxic
cell drugs are contraindicated.
function.

PIPERACILLIN-TAZOBACTAM
VITAMIN E Community-acquired and nosocomial
Protects RBC membranes against
pneumonia caused by piperacillin-
hemolysis, especially in low-birth-weight
resistan,
neonates.beta-lactamse producing
bacteria.
Bacillus clausii Bacillus clausii, has been found to produce
antimicrobial substances that are active against
gram positive bacteria including Staphylococcus
aureus, Enterococcus faecium, and Clostridium
difficile.

ZINC SULFATE Replacement and supplementation

therapy in patients who are at risk for zinc
deficiency, including patients in long term
parenteral nutrition.
 APPROACH

PALLOR JAUNDICE GROSS HEMATURIA

ANEM UNCONJ. CONJUGATED GLOMERULAR VASCULAR

IA BILIRUBI BILIRUBIN
N - Post >Hemolytic
DEC RBC INC RBC strep GN dse
>Hepatocel >Excretion
-
PROD. DESTRUCTION lular def Thalassem
disease -Dubin EXTRA
G6PD def ia
>Bone marrow failure >Intrinsic RBC defect -Hepatitis Johnson GLOMERULAR
-Aplastic anemiaAUTOIMMUNE
-Thalassemia A
Thalassemia
syndrome
G6PD def -Sickle cell
G6PD DEFICINECY anemia
SICKLE CELL ANEMIA HEMOLYTIC
Sicke cell
-Fanconi anemia
anemia -Sickle cell anemia
Hemolytic
>Hemolysis
anemia Tumor
Thalassemia
- Wilms
Hemolytic
-G6PD def
G6PD def - G6PD def -G6PD def -hemolytic
Sickle cell anemia
>Dietary deficiency - spherocytosis anemia
-IDA
DIC
ANEMIA
Hemolytic
anemia
-Thalassemi
Sickle cell
anemia
anemia>Extrinsic RBC defect a
-vit B12 deft
-folic acid
def
Aplastic -DIC -hemolytic
anemia -Hemolytic anemia anemia HEMOGLOBINURIA
>sickle cell
NORMOCYTIC,
-spherocyto
NORMOCHROMIC sis
ANEMIA >Crigler
 DIFFERENTIAL DIAGNOSIS
2.
1. SICKLE MAIN CLINICAL IMPRESSION
3.AUTOIMMUNE
G6PD DEFICIENCY
CELL ANMEIA
HEMOLYTIC ANEMIA
CHARACTERISTICS
CHARACTERISTICS
CHARACTERISTICS RULE
RULE IN
INLIKELY RULE
RULE OUT
UNLIKELY
OUT
Anemia
Acute or chronic body pain
malaise Cannot totally
CannotCannot rule
rule out
totally totally
out
weakness rule out


jaundice
Anemia G6PD DEFICIENCY



hematuria
hematuria
Jaundice
jaundice
anemia
Splenomegaly
diarrhea

pallor
Frontal bossing
Blood smear
tachycardia
hematuria
spherocytes &
polychromasia,
tachypnea
hypertension
nucleated RBCs
PBS: heinz
Growth body
retardation
+ DAT (hallmark)
 PATHOPHYSIOLOGY
Hexokinase G6PD
Glucose Glucose-6- 6-
phosphate Phosphogluconat
e
ATP ADP NADP+ NADP
H
Glutathione
reductase

GSSG 2 GSH

Oxidant stress Glutathio

Infections ne
Certain drugs peroxidas
Fava beans e
H2O2 2 H2O
 10 months,
ROS Male Infection

G6PD Cell membrane

Oxidized Hb deficiency damage
precipitates -Decreased
integrity
NADPH produced by
-Decreased
Heinz bodies HMP
flexibility
Hemolysis Drop in hgb
GSH produced using and hct
NADPH
Inc.
Hemoglobinuria Anemia
Bilirubin
ROS Infection
Jaundice Resolution Reticulocytosis
Long-term Management
MANAGEMENT
A. Antibacterial
. Nitrofurantoin
. Furazolidone
Fava beans
. Nitrofurazone/Nitrofural
Acetaminophen
inMethylene blue
Do
Keep not
your
ignore
list infections
of oxidative substances a
Red handy
wines place
B. Analgesic/Antipyretic
Arsine
Drugs to be .Aspirin
Menthol
Legumes
Acetanilid
Ascorbic acid
avoided Phenylhydrazine
Camphor
Blueberry
C. Anthelmintic
Parents should not give medications.without Toluidine
Chloramphenicolblue
doctors
Naphthalene
Memorize the signs and symptoms ofCiprofloxacin Soya
B-napthol,food
Niridazole,
hemolytic anemia
Trinitrotoluene
Henna
prescription
Chemicals to be Tonic
Stibophen water
Diphenhydramine
Aniline dyes
Herbs
The
Themost
mostimportant
avoided
Inform importanttherapeutic
Parentsmedical therapeuticmeasure
should remove
staff your measure
allbabys
D.

triggers
Bittermelon
Sulfonamides/Sulfone
Isoniazid
. Dapsone
from
G6PD Phenytoin
deficiency
their household
status
. Glyburide/Glibenclamide
Food/Drinks to be Quinidine
avoided
Let
for
forG6PD
If the G6PDdeficiency
themotherdeficiencyisisthe
child understand the
needs to takehis medication
condition
. Sulfacetamide
Phytomenadione
. Sulfamethoxazole
atlisted
the earliest
on the
. Sulfasalazine
PREVENTION
PREVENTIONOF
possible
trigger
Drugs list:
agein
safe
therapeutic doses OFHEMOLYSIS
HEMOLYSIS
E. Antimalarial
. Chloroquine/Primaquine
If there
Teach are no symptoms after taking
him to avoid foods and products awhich
food/drug
F. Miscellaneous that
can trigger
can trigger the hemolysis, patient should
hemolysis still avoid
. Dimercaprol
Others
taking them for their entire life . Probenecid
. Rasbucase