Name : MotiurAge : 3yrsSex : maleWeight : 12.5 kgFather’s name : Mr. MintuMother’s name: Mrs. Parvin Address :Comilla.D.O.A : 12 June 2010D.O.E : 12 June 2010

High grade intermittent fever for 15 days.Progressive Pallor for 7 DaysH/O per rectal bleeding for 7days

According to the statement of the mother her

child was reasonably well 15 days back. Then Motiur developed high grade intermittent fever not associated with chill and rigor and responded to antipyretics. Mother also noticed that her child started getting pale which was progressively increasing for last 7 days. She also gave H/O per rectal bleeding 7 days back. She gave no H/O jaundice, bodyache, respiratory difficulty, convulsion, vomiting or unconciousness.

He had no H/O taking any offending drug or exposure to radiation, blood transfusion or other bleeding menifestation, no H/O traveling to malaria or kala-azar endemic zone. For this illness he was treated by a local registered physician and was reffered to ICMH for better management.

Nothing significant.

Motiur was born at term by NVD at home with uneventful perinatal period.

FEEDING HISTORY

She was Exclusively Breast Fed up to 6 months.

Then formula milk, cows milk and suji was added along with breast milk .

She started to take family diet from 2 yrs of age.

DEVELOPMENTAL HISTORY

Developmentally he is age appropriate

IMMUNIZATION HISTORY

Immunized according to EPI schedule

FAMILY HISTORY

he is the 2nd issue of non-consanguineous parents.

he has one 4 yrs old brother.

All family members are healthy .

SOCIO-ECONOMIC HISTORY

Father - Farmer Mother - Housewife Lives in own kachcha house Drinks tube well water Use sanitary latrine.

GENERAL EXAMINATION

Appearance-Severely Ill looking, concious, irritable.

Temperature– 1020 F Anaemia – Severely pale Jaundice- Absent Cyanosis- Absent Oedema- Absent Dehydration- Absent Koilonychia- Absent

GENERAL EXAMINATION….

Pulse rate : 120/min BP : 90/60 mm of Hg R/R :30 breaths/min Lymph node : Cervical, Axillary and Inguinal

lymh nodes are palpable, size varying from2-3 cm, firm in consistency, non tender, not matted, free from overlying and underlying structure.

BCG mark :Present Skin Survey : Normal

Weight 12.5kg Height- 92 cm WAZ - -1.3 SD HAZ - -1.6SD WHZ - -1.4SDOFC - Normal

ANTHROPOMETRY

GENERAL EXAMINATION….

Ear :Normal Nose :Normal Throat :Normal

SYSTEMIC EXAMINATION(respiratory system)

Inspection Not dysphonicShape of the chest- normal

PalpationTrachea –central in positionExpansibility of the chest-normal

Percussion- Resonant

AuscultationBreath sound –Vesicular all over both lungs fieldNo Added sound

SYSTEMIC EXAMINATION(cardiovascular system)

Inspection –Precordium normal Palpation-

Apex beat- on left 5th IC space along left MCL. No parasternal heave

Percussion- Auscultation

S1,S2 – normal no added sound

SYSTEMIC EXAMINATION(hematological system)

Anaemia : Severe Jaundice : Absent Bony tenderness :Present Lymph node : Cervical, Axillary and

Inguinal lymh nodes are palpable, size varying from2-3 cm, firm in consistency, non tender, not matted, free from overlying and underlying structure.

Liver : palpable,4 cm from rt mid costal margin,firm in cinsistency with regular inferior border.

Spleen : palpable 5 cm from lt costal margin.

Skin & Mucous membrane : no bleeding spots

SYSTEMIC EXAMINATION(gastro-intestinal system)

Oral cavity– Gum-Not swollen, no bleeding spot– Tongue- pale– Tonsils - Normal

SYSTEMIC EXAMINATION(gastro-intestinal system)…..

Abdomen Inspection

Shape-normal No visible vein No visible peristalsisUmbilicus-Central in position,

inverted

Palpation– No tenderness, no lump Liver & spleen –

not palpableKidneys –Not

Ballotable Percussion- Tympanic Auscultation

Bowel sound-Present

Other systemic examination revealed normal

Motiur a 3 yrs old boy developmentally age appropriate immunized as per EPI 2nd issue of non-consanguineous parents belongs to a low socioeconomic background hailing from comilla had been admitted into ICMH on 12/06/2010 with the complaints of high grade intermittent fever for 15 days,progressive pallor for 7 days and H/O P/R bleeding 7 days back.

SALIENT FEATURESALIENT FEATURE

SALIENT FEATURE….

On examination Motiur was febrile, severely aneamic, nonicteric, acyanosed, nondehydrated having HR 120/min, RR 30/Min. She had bony tenderness , Cervical, Axillary and Inguinal lymh nodes are palpable, size varying from2-3 cm, firm in consistency, non tender, not matted, free from overlying and underlying structure

No other bleeding manifestation, Liver was palpable,4 cm from rt mid costal margin,firm in cinsistency with regular inferior border, Spleen palpable 5 cm from lt costal margin had no history of traveling to malaria or kala-azar endemic zone.

PROVISIONAL DIAGNOSIS

Acute Leukemia

DIFFERENTIAL DIAGNOSIS

Aplastic Anaemia. Thalassaemia. Malaria.

INVESTIGATIONS

CBCCBCHbHb : : 3.23.2 gm/dl gm/dlTC RBC TC RBC : 1.77 milion / cmm: 1.77 milion / cmmTC WBCTC WBC : 3.13 thousand/cmm: 3.13 thousand/cmmDCDC : : N- 6% L -92 %, M -1%, E -1%,N- 6% L -92 %, M -1%, E -1%, ESRESR : Not done: Not doneTC of platelet TC of platelet : 2,46,000cmm: 2,46,000cmm

INVESTIGATIONS..

PBF RBC - Anisochromia with mild

anisopoikilocytosis,mostly microcytes with frequent pencil shaped cells WBC - Mostly mature with mildly reduced total count,

lyphocytes predominance & few atypical cells are seen.

Platelet- Adequate in number. Comments : Bicytopenia with few atypical cells seen.

INVESTIGATIONS….

Bonemarrow examinationMyeloid/Erythroidratio – IncreasedErythropoiesis - Markedly depressedGranulopoiesis - Depressed

Marrow shows diffuse infiltration by numerus blastcells (95%). Blast cells are small, round

having monomorphic nuclei with coarse nuclear chromatin, low nucleo-cytoplasmic ratio & occasional single nucleus

Megakaryocyte - Are not seen.

Comments- Acute Lymphoblastic Leukaermia (ALL) FAB-L1

FINAL DIAGNOSIS

Acute Lymphoblastic Leukemia

(ALL) FAB-L1

Treatment givenGENERAL MANAGEMENT– Diet-Normal– Tab Multivit– Blood transfusion – 300ml (1 day after admission)– Councelling

SPECIFIC MANAGEMENTChemotherapy

For chemotherapy the patient is referred to Paediatric Heamato-oncology dept. of BSMMU on 17/06/10 after receiving Bone marrow examination report.

Follow up1st day 2nd day 3rd day 4th day 5th day

Appearance Sick Sick Sick Sick Sick

Anemia Severe Severe Severe Severe Severe

Any bleeding site

Absent Absent Absent Absent Absent

Bony tenderness

Absent Absent Absent Absent Absent

Jaundice Absent Absent Absent Absent Absent

Temp (0 F) 98 98 98 98 98

R/R (/min) 20 24 20 20 20

Pulse (/min) 100 100 100 100 100

BP (mm of Hg) 100/60 100/60 100/60 100/60 100/60

Bowel/Bladder Moved/Evac Moved/Evac Moved/Evac Moved/Evac Moved/Evac

Hb Level 3.2 5.2 5 -- --

Plane & done BT BM exam

(Not done yet)

BT givenBM exam

(Not done yet)

BM exam Done

-- BM exam report Received

Referral