NATIONAL BOGOMOLETS MEDICAL UNIVERSITY

PEDIATRIC DEPARTMENT № 4

The head of the department Prof Mityuryaeva-Korniyko I.O

Lecturer:

CASE HISTORY

PATIENT: Lily Johnson

Patient’s age: 10 months old

Diagnosis: Iron deficiency anemia, 2nd degree

Student’s name: amro azrak

Group: group 43

Curation date: 14/4/2023

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 PASSPORT DATA:

Patient’s name: Lily Johnson

Patient’s age: 10 months old

Hospitalization date: April 10, 2023

Admission diagnosis: Poor weight gain, fatigue, and pale skin

Hospitalization diagnosis: Iron deficiency anemia, 2nd degree

COMPLAINTS:

 Poor weight gain

 Fatigue

 Pale skin

PARTICULARIZATION OF MAIN COMPLAINTS:

Poor weight gain: Lily's mother noticed that Lily was not gaining weight as
expected for her age. She reported that Lily has been exclusively
breastfed and her appetite has decreased in the past few weeks.

Fatigue: Lily appeared tired and weak, and was less active than usual. She
slept more often and had less interest in playing

ANAMNESIS MORBI: Lily's mother reported that Lily was born full-term
and had no complications during delivery. Lily had been healthy since
birth, with no previous hospitalizations or major illnesses. However, she
mentioned that Lily's iron levels were low during her last doctor's visit.

ANAMNESIS VITAE: Lily lives with her mother, father, and older brother in
a small apartment. The family has access to clean water and adequate
sanitation. Lily's mother breastfeeds her exclusively and has started giving
her solid foods recently.
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OBSTETRICAL ANAMNESIS: Lily's mother had an uncomplicated pregnancy
and received regular prenatal care. She did not have any infections during
pregnancy and did not take any medications.

PHYSICAL DEVELOPMENT OF A CHILD:

 Body weight: 7.5 kg

 Height / body length: 70 cm

 Physical development evaluation: Lily appeared small for her age

and was in the 10th percentile for weight and height.

NEURAL-AND-BEHAVIORAL DEVELOPMENT OF A CHILD:

 Psycho-motor functions maturation: Lily's mother reported that Lily

started crawling at 8 months and has not started walking yet.

 Psychical development: Lily's mother reported that Lily was

generally happy and sociable.

 Feeding: Lily was exclusively breastfed for the first 6 months of life,
and has been receiving solid foods since then.

INFECTIOUS DISEASES IN CHRONOLOGICAL ORDER: Lily had no history of

infectious diseases.

PROPHYLACTIC IMMUNIZATIONS AND POSTVACCINAL REACTIONS AND

COMPLICATIONS: Lily has received all her recommended immunizations
without any complications.

TUBERCULIN TESTS: Lily has not had any tuberculin tests.

ALLERGOLOGICAL ANAMNESIS: Lily's mother reported no history of

allergies or allergic reactions.

SOCIAL-AND-LIFE CONDITIONS: Lily's family lives in a small apartment in a

low-income area. Both parents are employed, but their income is limited.

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FAMILY ANAMNESIS: There was no family history of anemia or other
significant medical conditions.

EPIDEMIOLOGIC ANAMNESIS: Lily had not been in contact with anyone

with a contagious disease recently.

STATUS PRAESENS OBJECTIVUS:

 General condition of a patient: Lily appeared tired and weak.

 Position of a child in the bed: Lily was lying on her back.

 Body temperature: 37.2°C

 NERVOUS SYSTEM:

 Consciousness: Alert and responsive.

 Behavior: Appeared tired and less active than usual.

 Sleep: Slept more often than usual.

 Memory: N/A

 Speech: N/A

 Intellect: N/A

 Manner of walking: N/A

 Body structure: Lily appeared small for her age.

 Skin: Pale in color

 Rash elements: None noted

 Hair: Normal

 Nails: Pale and brittle

 Dermographism: Negative
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  Subcutaneous fatty tissue: Decreased thickness

 Distribution: Evenly distributed

 Edemas: None noted

 Soft tissue turgor: Normal

 Lymph nodes: Not enlarged or tender

 Musculo-skeletal system: Vertebral column and extremities were

normal. No joint abnormalities noted.

 Head: Normal

 Face: Normal

 Eyes: Conjunctiva pale, pupils equal and reactive to light, no

jaundice or scleral icterus

 Nose: No abnormalities noted

 Neck: Supple, no lymphadenopathy or thyromegaly

 Oral cavity: Normal

 Respiratory system:

 Inspection of the chest: Chest appears slightly flattened with

increased AP diameter, mild intercostal retraction, and visible
costal margins

 Palpation of the chest: Decreased elasticity and resistance of

the chest wall, no pain noted, decreased vocal fremitus

 Percussion: Dullness over the lower half of the chest,

particularly in the left side

Research of respiratory organs

Nasal free breathing. Auxiliary muscles do not participate in the act of

breathing. Excursion of the chest in full. The breast cell is of a regular
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shape, normostenichesky, symmetric triangular, both halves actively
participate in the act of breathing. The type of breathing is mixed, the
depth is average, the frequency is 20 per minute, the rhythm is correct.
Upon palpation of the chest, there is a painless, elastic, voice-over sound
in symmetrical areas of one-sided force. With comparative percussion,
the same lung sound is clear from the two st pro rons. Symptoms of
Kornig, Arkavina, Filosofov cup are negative.

Heart region examination:

Palpation:

 Apex thrust: No significant apex beat was palpable.

 Pulse characteristics: The radial pulse was regular with a rate of 110
beats per minute and normal volume.

Percussion:

 Right border of the relative heart dullness: The right border of the
relative heart dullness was in the fifth intercostal space, 1 cm from
the right sternal border.

 Upper border of the relative heart dullness: The upper border of the
relative heart dullness was in the second intercostal space, 2 cm
from the left sternal border.

 Left border of the relative heart dullness: The left border of the
relative heart dullness was in the fifth intercostal space, 9 cm from
the left sternal border.

Auscultation:

 Heart sounds: The first heart sound (S1) was heard as a loud and
clear lub sound, followed by a soft and shorter dub sound of the
second heart sound (S2). No additional heart sounds or murmurs
were detected.

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  Lung sounds: The breath sounds were diminished bilaterally, with
no adventitious sounds detected.

Arterial pressure: The blood pressure was measured and found to be

within normal limits for a child of this age. The systolic blood
pressure was 95 mmHg, and the diastolic blood pressure was 60
mmHg.

DIGESTIVE SYSTEM:

The abdomen appears flat and symmetrical with no visible

distension. The abdomen participates normally in respiration.
Superficial palpation reveals no tenderness, and the liver and spleen
are not palpable. Deep palpation reveals no palpable masses, and the
sigmoid colon, caecum, ascending colon, transversal colon, and
descending colon are not tender.

The liver can be palpated near the edge of the costal arch, it is
painless, its edge is smooth, elastic, rounded, it is easily rolled up.

Symptoms of Ker, Murphy, Musse, Ortner are negative.

The pancreas is not palpable. The spleen is not palpable

Study of kidneys, bladder

Peripheral edema is not detected during examination. The kidneys

are not palpable. Ureter points are painless. The bladder does not
protrude above the womb, it is not palpable. The symptom of pain in
the lumbar region is negative on both sides. Physiological shipments
without and with meny.

reproductive system

The genitals are formed correctly, according to the male type. Eggs
are lowered into the scrotum, painless on palpation.

Physical development at the time of examination

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 Physical development of the mesosomatic type, harmonious.

PRELIMINARY DIAGNOSIS COMPOSITION

Based on the child's complaints, anamnestic data, and objective

inspection results, it is possible to make the preliminary diagnosis of
iron-deficiency anemia of 2nd degree.

pale skin, brittle hair, dry and brittle nails, dermographism, reduced
subcutaneous fatty tissue, turgor of soft tissue
LABORATORY AND INSTRUMENTAL EXAMINATIONS:

Complete blood count (CBC): The CBC showed low hemoglobin levels (7 g/dL) and low
mean corpuscular volume (MCV) (70 fL), indicating microcytic hypochromic anemia.

Iron studies: Serum iron and ferritin levels were low, and total iron-binding capacity (TIBC)
was elevated, suggesting iron deficiency anemia.

Stool examination: Stool examination was negative for parasites and occult blood.

DIFFERENTIAL DIAGNOSIS:

Other possible causes of poor weight gain, fatigue, and pale skin in a 10-month-old child
include:

1. Other types of anemia such as thalassemia or sickle cell anemia.

2. Infections such as urinary tract infection, respiratory tract infections, or
gastrointestinal infections.
3. Malabsorption syndromes such as celiac disease or inflammatory bowel disease.
4. Congenital heart disease or heart failure.

However, based on Lily's symptoms and laboratory results, the most likely diagnosis is iron
deficiency anemia, 2nd degree.

Main diagnosis: Iron deficiency anemia, 2nd degree

Complications: None reported

Concomitant diagnosis: None reported

TREATMENT:

The treatment plan for Lily's iron deficiency anemia, 2nd degree includes:

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 1. Iron supplementation: Lily will be prescribed oral iron supplements in the form of
ferrous sulfate drops, to be given once a day. The dosage will be calculated based
on her weight.
2. Dietary changes: Lily's mother will be advised to introduce iron-rich foods in Lily's
diet such as meat, fish, poultry, legumes, and fortified cereals.
3. Follow-up: Lily will be scheduled for regular follow-up visits with her pediatrician to
monitor her hemoglobin levels and response to treatment.

In addition to the above, Lily's mother will also be advised on ways to improve her
breastfeeding technique and frequency to ensure that Lily is getting adequate nutrition.

It is important that Lily completes the full course of treatment and follows the dietary
recommendations to ensure a successful recovery.

Date:________________ Curator’s signature________________

Points/traditional mark________________ Lecturer’s signature_______________