《儿科学》课程作业习题（典型病例）04 iron deficiency anemia

Medical number:667056Main diagnosis: Iron Deficiency Anemia (IDA)History summary:Boy,ninemonths and thirteen daysMain complaints: facial pale for9 months.skin had no yellowand purple.Three days ago, he turned to be faint, poor-feedingand upset with yellowskin and water-like diarrhea. One day ago, he was sent to see aoctorse of fever (T37.4C).As his blood routine test showed HB56g/L, MICV51fL,MCH15.2ps，MCHC298g/L,dvised togoto our hospital forfurthenill-birth, heweeks (about 8 and half months). He is Caesarean birth for premature rupture of fetalmembranes, and his birth weight was 1.95KgHe had no evidence of suffocate,but the Apgarscorewasungclear.Hewasfed withcowsmilkforfirst3-4dayspostnatal,thenwithbreasmilk until 10 day.His motherconsidered thequantityof herbreastmilkdeed sincethebalittortifiedwithiaddetfle:Family history:His mother presented with pale, weakness, and she was considered withanemia without clear diagnosis by doctor, unclear oral drug was given without CBC testesult.His uncle was uncertain anemiaPE:T36.5C.HR124bpm,RR 30/min, Wt 9.5Kg, head, chest and abdominal circumferencesor 45.5cm, 46.5cm,43.5cm and 72cm, respectively.He is awake andsluggishnessemia appearance, no jaundice. His chest is clear to auscultation, hiswithmaiorheart beat isnormalHislivercan betouched 3cm bellowtheright costal border,theplencanotbetouchecInvestigation tests:(1) Blood roDATERBC(×1012/L)HB(g/L)MCV(g/L)MCH(pg)MCHC(g/L)3.64.1463164.5115.21236114.8↓24413.74.0560160.714.62CA69118.2↓26313.92)Periperalbodsmarshows anicyosishyphomPO00000:00900normalIDA (anisocytosis(2) Serum Iron (SI)4.09umol/L, total iron binding capacity (TIBC) 80.8μmol/L, saturation rate oftransferrin(SF)5.1%

Medical number: 667056 Main diagnosis：Iron Deficiency Anemia（IDA） History summary: 1. Boy, nine months and thirteen days. 2. Main complaints: facial pale for 9 months. 3. Current history: His father discovered the boy non-progressive pale after birth. The boy’s skin had no yellowish, bruise and purple. Three days ago, he turned to be faint, poor-feeding and upset with yellowish skin and water-like diarrhea. One day ago, he was sent to see a doctor because of fever (T 37.4℃). As his blood routine test showed HB 56g/L, MCV 51fL, MCH 15.2pg，MCHC 298g/L, he was advised to go to our hospital for further researching. 4. Personal history: The 1st gestation was still-birth, he is the 2nd gestation with 36 gestational weeks (about 8 and half months). He is Caesarean birth for premature rupture of fetal membranes, and his birth weight was 1.95Kg. He had no evidence of suffocate, but the Apgar score was unclear. He was fed with cow’s milk for first 3-4 days postnatal, then with breast milk until 10 days ago. His mother considered the quantity of her breast milk decreased since the baby was 3 months old. A little cereal fortified with iron, zinc and calcium was added since his 5 th month, noodle was given since 9th month, and little meat was given 10 days ago. 5. Family history: His mother presented with pale, weakness, and she was considered with anemia without clear diagnosis by doctor, unclear oral drug was given without CBC test result. His uncle was uncertain anemia. 6. PE: T 36.5℃, HR 124bpm, RR 30/min, Wt 9.5Kg, head, chest and abdominal circumferences, heighth account for 45.5cm, 46.5cm, 43.5cm and 72cm, respectively. He is awake and sluggishness with major anemia appearance, no jaundice. His chest is clear to auscultation, his heart beat is normal. His liver can be touched 3cm bellow the right costal border, the spleen can not be touched. 7. Investigation tests: (1) Blood routine test: DATE RBC(×10 12 /L) HB(g/L) MCV(g/L) MCH(pg) MCHC(g/L) 3.6 4.14 63↓ 64.5↓ 15.2↓ 236↓ 3.7 4.05 60↓ 60.7↓ 14.8↓ 244↓ 3.9 4.62 84↓ 69↓ 18.2↓ 263↓ (2) Peripheral blood smear shows anisocytosis, hypochromic. normal IDA（anisocytosis) (2) Serum Iron (SI) 4.09μmol/L, total iron binding capacity (TIBC) 80.8μmol/L, saturation rate of transferrin(SF) 5.1%

(3) Hemoglobin fetal (HbF) 1.2%, HbA2, hemoglobin electrophoresis and gene mutation test forXB-thalamiawerenorma(4) Lab test for liver, renal and cardiac function,electrolyte, bleeding test were normalTreatment:100ml RBCtransfused for severe anemia, and oral Iron Dextran and VitC was admittedforIDAOuteThe boy looked rosy, no fever, cough or diarrhea. Before discharge, rechecked CBC testshowed Hb 84g/LFollow-up:3months CBC following-up in clinic.Nutritional education: he should be given iron-rich food such as pork liver, fish, beef ands, meanwhile, VitC-rich food should berecommendedtoadvantageironabsorptior3.Following therapy: Iron Dextran, 5ml bid (between 2meals); VitC 10mg bid. The treatmentwill be kept till 2 or 3 months after CBC test is normal

(3) Hemoglobin fetal (HbF) 1.2%, HbA2, hemoglobin electrophoresis and gene mutation test for α, β-thalassemia were normal. (4) Lab test for liver, renal and cardiac function, electrolyte, bleeding test were normal. Treatment: 100ml RBC was transfused for severe anemia, and oral Iron Dextran and VitC was admitted for IDA. Outcome: The boy looked rosy, no fever, cough or diarrhea. Before discharge, rechecked CBC test showed Hb 84g/L. Follow-up: 1. 3months CBC following-up in clinic. 2. Nutritional education: he should be given iron-rich food, such as pork liver, fish, beef and eggs, meanwhile, VitC-rich food should be recommended to advantage iron absorption. 3. Following therapy: Iron Dextran, 5ml bid (between 2meals); VitC 100mg bid. The treatment will be kept till 2 or 3 months after CBC test is normal