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Combined Clinical case discussion

Combined Clinical case discussion. Name: Manjunath Age: 2yrs 10mo Sex: Male Addr: Channandur Gouribidanoor (Tq) Kolar (Dt) D.O.A: 4-10-04

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Combined Clinical case discussion

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  1. Combined Clinical case discussion

  2. Name:Manjunath Age: 2yrs 10mo Sex: Male Addr: Channandur Gouribidanoor (Tq) Kolar (Dt) D.O.A: 4-10-04 Informant: Grand mother(Reliable)

  3. Presenting complaints • Not able to stand even with support since birth • Deformity of left upper limb & pain on touching it------Since 3 months • Keeping the head turned to left side—Since 21/2 mon

  4. History of presenting complaints • Grand mother noticed that child is not able to stand even with support at this age. when child was made to stand with support he used to lift his legs off the ground without supporting his body wt on legs.But he attained neck controle at 4th month,sitting with support at 6th mo,sitting without support at around 9 mo.Feed hiself successfully at 18 mo,holds pen & scribble at 11/2 yr

  5. History of presenting complaints • Social smile around 21/2 mo, waving bye-bye at 1yr & now plays with other siblings normally • Using bisyllables around 1yr(Ajji,jiyya) • Now child goes from one part of room to other by shuffling

  6. Grand mother thought that child will start walking only after 3 yrs of age i.e.after his mother’s delivery & after offering his hair to the God Manjunatha at 3 yrs of age. • For above reasons child was not shown to any doctor. • 3 mo back gr mother noticed the deformity over child’s Lt forearm i.e. curved fore arm bones & child used to cry on touching the limb.

  7. She doesn’t remember any antecedent h/o truama or fall • Movements at wrist or elbow were not restricted & there was no abnormal movement at the site of deformity. • She also complained that child always used to keep his head turned to left side & could not turn to rt side completely.

  8. Used to cry excessively when gr mother tried to move the neck to Rt side No h/o trauma to the neck But gr mother tells that child is not puttingon wt & in fact child has lost wt. Grand mother also c/o polyuria & polydypsia No h/s/o recurrent cough & chest retraction No h/o deformities in other limbs,no h/o drug intake no h/o ear dicharge or vision defect

  9. For similar complaints child was taken to some nati vaidya for puttur bone castphysician in gouribidanoor govt hosppediatricinadv to go to VVCH • PAST HISTORY: At the age of 1yr had fever lasting 3-4 days/mo for 2-3 months associated with nasal discharge Rx on opd basis in Koratagere. Child also had loose stools lasting for abt 15 days

  10. 5-6 episodes/day,small qty,watery in cons,foul smelling & was Rx on opd basis with inj & syr but no I.v. fluids.After child was branded on back in lumbar region, it subsided. Child had convlsions at the age of 11/2 yr,3-4 episodes, each lasting for abt 2-3 min.it was in the form of tonic posturing of limbs.No h/o post- ictal drowsiness or bowel/bladder incontinence & it subsided after branding & no Rx was given

  11. 6 • Family history: ML--5 yrs no similar compl in family 18 28 No deaths or abortion 6months 2yrs10mo

  12. 6

  13. Birth history • Ante natal—B&I at GH 2TT inj taken.>100 IFA taken All trimisters were unevntfull NATAL: Full term delivery by LSCS in Gouribidanoor Pvt N.H. ?indi CPD.duration of labor was around 24 hrs. BCIAB birth wt—2.75kg no NICU admission.breast fed immediately

  14. POST NATAL: Un eventful(no jaundice) FEEDING HISTORY: Braest fed immediately after birth No pre lacteal feeds,was breast fed for 1yr Weaned at 5th with ragi seri , ghee & cow’s milk After 9 mo started giving rice in the afternoon & ragi seri at night

  15. Present diet • TIME Calories Proteins 6am. 1 cup milk with water 60 3 1:1 dil C sugar+2pcs bread 20+140 4 10 am ¼ ragi ball +1/2 cup rice 30+80 2+1 C sambar & 1 tsp ghee 40 --- 12 NOON 2 biscuits 40 1

  16. 2PM ½ cup rice c sambar 80+10 2.5 4PM Milk 60ml(1:1)dil c 2 biscuits & sugar 60+40+20 3+1 8PM ¼ ragi ball+1/2 cup rice 120 3 c sambar 740kcal 20gms

  17. Immunisation history Upto date Developmental history Neck controle--4thmonth Rolling over—6th month Sitting without support—81/2 months Creeping –1yr Standing with support ---not yet attained

  18. Fine motor • Attained pincer grasp---10months Can feed himself without spillage Plays with toys normally LANGUAGE Uses only bisyllables like ajji thatha & jiyya can not make sentences. Social: normal ,plays with siblings ,recognises relatives.

  19. Socio economic history • Father—5th std,coolie works in fields,Rs 30/day Mother—8th std,H.W. 5 membered family,father is only earning member. own house,pakka house with mud floor,2 windows,1 door &no sep rooms,open air defecation - lower SES

  20. Summary 2yrs 10 months old child came with h/o not able to stand even with support. Deformity of Lt UL C tender to touch—3mo Keeping head turned to Lt—21/2 mo C no h/o trauma/fall H/o polydypsia & poly uria C past h/o febrile convlsion & loose stools & no significant ?family history C gross & language developmental delay

  21. Provisional diagnosis 1 Resistant rickets —Adequate diet -- Adequate sun exposure --Failure to thrive -- Fracture 2 Renal tubular acidosis –Rickets feature -- Polyuria & polydypsia - Failure to thrive

  22. GPE • 2yrs 10mos old child is sittting in gr mother’s lap comfortably, conscious but irritable for examination. Anthropometry Wt--------7kgs 3rd perc11.4,50th per 14.3. <50% Length—70cm <3rd percentile(88cm) stunted H.C.------46cm expected 47—50cms C.C.------43cm not over taken the head circmf MAC-----12cm severe mal nutrition

  23. Comments • Child is both stunted & wasted • Wt age= 6 months • Ht age = 6 months • WT/HT= normal • HC =1 yr • UL/LL= 1.2 proportionate dwarf

  24. Vitals • Afebrile • RR-28/min • Pulse rate-98/min • BP-92/60 • Hydration -adequate

  25. Head to toe examination • Head –parietal prominance+ AF-open 3x3 cm,PF-closed,no ping- pong ball feel Eyes:appear prominantn,no blue sclera,no pallor Nose:upturned nares with broad base Ears: normal Oral cavity:hygenic

  26. Dentition; 112 211 no caries& other anomalies 112 211 Neck;: no restricted novements,no LN pathy no mass in sternocleido mastoid muscle Chest:costo chondral beading+ rounded,no harrison sulcus Abdomen:protruberant Spine:no kypho scoliosis Bones & joints:Deformity of Lt fore arm+

  27. Left fore arm:deformity+,curved forearm bones,tender to touch. no crepitous or psuedo arthrosis

  28. Wrists—widening + • Ankle—double malleoli

  29. Systemic examination • CVS– normal s1 s2 heard no murmur • RS:b/l equal chest movement NVBS+,occ crept+ • P/A: soft,protrberant liver palpable 1.5 cm RCM, BS+

  30. Provisional Dx • Resistant Rickets with GR IV PEM • Osteogenesis imperfecta type IV • RTA

  31. URINE: PH-5.5 , Sp. Gravity 1.010 aminoacidurias—Neg 24 hrs urinary ca++ 240mg/dl high N 24 hrs urinary posp—120mg/dl Normal • Blood urea—30mg% • Serum creatinine—0.1mg% • ABG:PH:7.36 PCO2:38 PO2:44 Na:137, HCO3:21.8 BE:3. O2 sat:79.7

  32. X-ray UL-multiple # on both ulnas with gen osteoporosis 2 carpal bones are+ X-ray femora—generalised osteoporosis+,No # X-ray skull– no wormian bones,C-spine normal • X-ray LL:Generalised osteoporosis+ C green stick # of Lt tibia at middle of shaft. • U/S abdomen:Rt kidney is not visualized ?Agenesis?ectopic

  33. Diagnosis

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