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 .

Past Medical Hx
1.Tonsillitis
2.Cold and flu

Surgical Hx - Nil
Trauma Hx - No prior trauma
Medication Hx Amoxil , Ibuprofen
Allergy Hx No Allergies
Transfusion - Nil

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

18/08/2016
Discharge
Malaria : -ve
Stool : -ve
Hb : 12 g/Dl
Crushed Food Feed

Differential Dx
G-6-PD deficiency, hemolytic episode
Hemolytic disease of newborn
Anemia of Prematurity