HISTORY TAKING

Personal Identification

Name : Ranganath Beerannavar

Age : 8 years old

Sex : Male

Religion : Hindu

in

Address : Belgaum

Date of Admission : 6/03/2019

Date of Clerking : 6/03/2019

IP Number : 932166

Informant : 1) Mother – Reliable

Chief Complaints

- Came to the hospital for monthly transfusion of blood on 6/3/2019

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consanguinity

History of Presenting Illness

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Patient was first diagnosed with thalassemia at during his first year of life when he came to the
hospital complaining of fever and cough. On routine investigation, he was found to have low levels of
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Tetost Tttsessfospst
hemoglobin. He was then referred to the KLE Hospital. On further investigation at the KLE Hospital, a bone

astounded
marrow examination was done and he was given blood transfusions. Patient is now undergoing treatment of

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receiving monthly blood transfusions at the KLE Hospital.

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No history abdominal pain, joint pain or changes in skin colour. No history of bleeding, swelling of lower

limbs, yellowish discolouration of skin or deafness.

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Past Medical & Surgical History


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Patient has been admitted to the hospital multiple times to undergo blood transfusion. He is not a

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known case of diabetes mellitus, hypertension, tuberculosis or asthma. He has never undergone any kind of

surgery before but has undergone a bone marrow examination. No history of trauma or accidents.

Past Treatment History

Patient is currently taking some medications for his condition. The medications are Defarasirox (oral iron

chelator), B-Complex, folic acid tablets and Zincovit multivitamins. However, the duration of the

pharmacological treatment could not be elicited.

Family History

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The patient is a child born out of a 2nd degree consanguineous marriage. He is the only child in

the family. His mother and father are currently 24 and 30 years old, respectively.

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There are no similar conditions in the family. There is also no history of genetic diseases or

congenital anomalies in the family. There is no known chronic illness such as Diabetes Mellitus and

hypertension in the family. There is no known incidences of sudden deaths in the family.

History of Contact

According to the mother, there is no history of contact with an open case of tuberculosis, a

patient undergoing antitubercular treatment or a patient with a chronic cough and fever.

There is also no history of recent travels.

Birth History

1) Antenatal History

The pregnancy was confirmed at a government hospital at the maternal age of 16 years old. The

mother went for regular antenatal check ups at a local hospital. An ultrasonography scan was done at

the 3rd,5th and 6th month of pregnancy. The ultrasonography scan at the 6th month of pregnancy

revealed a cleft lip and a cleft palate.

She did not take any medication during pregnancy except for the required folic acid and iron

supplement which was prescribed by her doctor. She was also given two doses of the tetanus toxoid

vaccine. There was no history of pregnancy-induced hypertension (PIH), Diabetes Mellitus,

convulsion, radiation to exposure or any infection during this period. The mother did not smoke or

consume alcohol throughout the pregnancy.

During the first trimester, there were no complications. Folic acid supplements were taken

accordingly a month before conception. There was no history of prolonged fever with rashes,

swelling of the neck, burning micturition or per vaginal bleeding. There was no history of any

infections either. She went for regular antenatal check ups.

The second trimester also did not show any complications. Quickening was felt during the 6th

month of pregnancy. Iron and calcium supplements were taken regularly. An Anti-Tetanus Toxoid

injection was also received by the mother. There was no history of pregnancy induced hypertension

or gestational diabetes mellitus. She went for regular antenatal check ups.

The third trimester went well. There was an appropriate maternal weight gain. There was no

history of abdominal pain, per vaginal bleeding or per vaginal leaking. Iron and calcium supplements

were taken regularly. There was no history of exposure to radiation.

convulsion

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feedingdifficulties

jaundice
2) Natal History

respiratory distress syndrome

The patient was born at full term (9 months and 6 days) via a normal delivery at the Badani

Hospital. The patient was born with a very low birth weight of 1.5kg. The patient cried immediately

after birth.

3) Post Natal History

At 1 hour of life, patient was convulsing and was then admitted to the NICU for 11 days. There

is no history of feeding difficulties, jaundice or respiratory distress syndrome.

Immunization History

Age Birth – 6th week 10th 14th 9th 12th 6 years

Vaccine 2 weeks week week month month

BCG /

OPV / / / /

DPT / / / Booster

Measles /

MMR /

Hepatitis B / / /

Tetanus

toxoid

- The patient has received the BCG vaccine which is proven by the scar on his left upper arm.

- He is immunized according to his age as per the National Immunization Programme

schedule.

- His latest immunization is the DPT booster at the age of 6 years old.

- There is no history of being administered additional vaccines such as the pneumococcal

vaccine. (important for splenectomy)

menigococcal

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Developmental History

GROSS MOTOR SKILLS

Head control 5 months

Rolling over 6 months

SOCIAL ADAPTIVE SKILLS

Social smile 3 months

Recognition of mother 3 months

1
Stranger anxiety 6 months
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LANGUAGE & SPEECH DEVELOPMENT

Cooing sounds 5 months

l I
Monosyllables 6 months

Visual and hearing within normal limits. All developmental milestones were achieved at appropriate

age and time without any delay. Patient is currently in primary school.

Dietary History

Patient was breastfed only 4 days after delivery with exclusive breast milk. The duration of

exclusive breastfeeding was for 5 months. Weaning started at the fifth month via top-feeding of

ragi, ganji, biscuits and rice ganji. The total duration of breastfeeding was for 8 months.

Present Diet:

Food Intake Quantity Calories Protein (gm)

(kCal)

Breakfast

Idli 3 150 6

E 3 I I

Chai 1 cup 60 1.0

Sambar 1 50 2.5

Lunch

Rice 1 175 4

S I I

Sambhar

Chicken
S1

1
50

109
2.5

26

Evening

Biscuits 3 60 1.5

Chai f C
1 cup I
60
2
1.0

Dinner

Rice 1 175 4

F L I I

Sambar 1 50 2.5

Chai 1 cup 60 1.0

Total calorie intake: 999 kCal/day

Recommended value: 1700 kCal/day

Difference: 701 kCal (deficient)

Total protein intake: 52 gm/day

Recommended value: 39 gm/day

Difference: 12.1 gm (additional)

- Patient is advised to consume a lower iron intake due to risk of iron overload.

Socioeconomic Status

His parents both work as odd job workers. The father has a middle school certificate. The family

has a monthly income of 8000 rupees per month. They live in a Katcha house with a total of 4

people in 1 room. Overcrowding is present. The source of water is inside the house. However, the

water is not boiled before drinking. The ventilation and the lighting of the house is poor. According

to the Kuppuswamy Classification, the family is situated in the lower middle class.

Summary

Ranganath, an 8 year old boy came to the hospital to receive his monthly blood transfusion for

thalassemia. He denied any history of symptoms of iron overload or any hematological disorders.

He is a child born out of a 2nd degree consanguineous marriage. There are no similar complaints in

his family. After he was born, he had a convulsion and was admitted to the NICU for 11 days. His

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immunization and developmental history are uneventful. His dietary history shows that he is calorie

deficient and his socioeconomic history puts him in the lower middle class family.

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