Case Scenario

A 2 year old male child named Sonu having 10 Kg weight and height 88 cms lives with his
parents. His Father is Mr Senthil, 28 yrs old, educated upto 12 th std working as a driver and
earns Rs.12000 per month. His mother is Mrs Sunita, 25 yrs old house wife, having
education upto 8th std. The child came for regular health checkup.

As for ANC history, she was registered, had regular ante natal checkups. She was given one
dose of TT injection during her antenatal period when she was bearing Sonu. She regularly
took iron and folic acid tablets and had no problems in her antenatal period. Sonu was born
on 12 February 2019 by caesarian section in govt hospital, Chrompet. Mrs Sunita told that
Sonu cried immediately after birth and was breastfed within 4 hrs. She told her son was
vaccinated soon after birth and has been given all vaccines against all the vaccine
preventable diseases as advised by Doctor and as per the schedule given in immunization
card. Sonu’s mother gave exclusive breast feed for 6 months and after 6 months,
complementary feeding was started. Mrs Sunita told all the milestones of his son were
normal and he did not have any growth or development problem. For their routine medical
or health problem, they go to anakaputhur PHC. Sonu is well-built, well-nourished and
active child. His pulse rate is 90 beats per min and resp rate is 20/min. On head to toe
examination no deformity was found. All his systemic examinations are normal. He has one
elder sister Anshu who is 8 yrs old who also was delivered by caesarian section. The
previous caesarian section was emergency as the cord was around the neck of the fetus
which was detected by scan in third trimester. As told by mother, now Anshu is also normal.
Her growth and development history were normal.

They live in one-bedroom semipucca house with poor ventilation and having poor
sanitation in an urban slum in Anakaputhur, Chennai. Mrs Sunita told Sonu is an active child
and playing in and around the house with his toys as he is not going to preschool due to
covid 19 lockdown.

Sonu’s Dietary history:

Morning ½ Idli or ½ Dosa witj ½ cup milk.

10 am 2 biscuits ½ cup milk.

Lunch ½ cup rice with 2 tablespoon Sāmbhar and 2 table spoon curd.

Evening 2 rusk with ½ cup milk.

Dinner 1/2 chapati with 1 tablespoon vegetable curry.

1. Write the relevant history pertaining to the given case scenario in detail.
2. List out the general physical and systemic Examination details.
3. Write a provisional diagnosis and about the management of this case.