APPROACH TO CHILD

WITH SKELETAL
ABNORMALITIES
MODERATOR- DR.VIJAY BIRADAR SIR
DR. M.M PATIL SIR
DR. KUMAR ANGADI SIR
PRESENTER- DR.VENKATESH REDDY.A
DEMOGRAPHIC DETAILS
NAME- ABC
AGE- 18 months
SEX- Female
ADDRESS- Bijapur
INFORMANT- Mother (reliable)
24years.
CHIEF COMPLAINTS
H/o not gaining weight since 1 year of age.
H/o bowing of legs observed since last 6 months
H/o frequent fall while walking since last 2 months.
HISTORY OF PRESENTING ILLNESS
- Child was apparently alright 6 months back then mother noticed child is not gaining weight
adequately before which weight gain was adequate.
- Also give history of bowing of legs observed first at 1 year of age, which is not progressive in
nature.
- Mother also noticed frequent falls while walking without support since last 2 months.

- No h/o fever and yellowish discolouration of skin and sclera

- No h/o vomiting, loose stools.
- No h/o bulky stools, foul smelling stools.
- No h/o delayed dentition.
- No history suggestive of carpopedal spasm.
- No history s/o tetany.
- No h/o seizures, lethargy
- no h/o night blindness, rashes, ataxia
- No h/o polyuria, oliguria and bone pain.
PAST HISTORY
- No h/o previous hospitalizations, or usage of AED
- No h/o recurrent respiratory tract infections
ANTENATAL HISTORY
- Pregnancy confirmed by UPT at 2 months of amenorrhea.
- Booked case, 2 TT doses taken.
- Antenatal scans were done at 4th and 6th months of pregnancy
- Iron, calcium and folic acid supplementation were taken.
- no h/o exposure to radiation and drug usage.
NATAL HISTORY
- Full term normal vaginal delivery at civil hospital, Sindagi.
- Baby cried at birth
- Birth weight of 3kgs.
- No h/o nicu admission.
POSTNATAL HISTORY
- No h/s/o neonatal convulsions.
- No h/o breathing difficulties.
- Exclusively breastfed till 6 months of age then complementary feeds were started at
6 months of age with rice ganji.
FAMILY HISTORY
- Elder sister had similar complaint of bowing of legs which mother noticed at 1 year
of age for which she was taken to pediatrician, evaluated and treated with I.M
injections every weekly and relieved of symptoms now.
PEDIGREE CHART
- Nonconsanginous
marriage.
- 3rd in birth order
- 1st child preterm
Death due to
CHD.
DIET HISTORY
- By 24hour recall method
Child is taking 595 kCal/day and 16 gram/day of protein intake.
Expected calories- 1100 kcal/day (deficit by 50%)
Expected protein is 12 grams/day (adequate).
CALORIE INTAKE PROTEIN INTAKE
(KCAL/DAY) (GRAMS/DAY)

BREAKFAST- uppittu 135 kcal 2

LUNCH- dal rice 180 kcal 5

SNACKS- biscuits(4) 100 kcal 4

DINNER- dal rice 180 kcal 5

TOTAL 595 kcal 16 grams/day

 DEVELOPMENTAL HISTORY
All developmental milestones attained as per age
Milestone
.

Attained
Expected

GROSS MOTOR MILESTONES

Milestone Attained Expected

Neck holding 3 months 3 months
Rolling over 5 months 5 months
Sits with support 6 months 6 months
Sits without support 9 months 8 months
Standing with support 10months 9 months
Walks with support 13 months 12 months

Walks without support 16 months 18 months

 FINE MOTOR MILESTONES

Milestone Attained Expected

Bidextrous reach 4 months 4m
Unidextrous reach 7 months 6m
Immature pincer grasp 9 months 9m
Mature pincer grasp 14 months 12m
Immitates scribbling 16 months 15m
 LANGUAGE MILESTONES

Milestone Attained expected

Alerts to sound 1 months 1m
Cooing 2 months 3m
Laughs loud 4 months 4m
monosyllables 7 months 6m
Bisyllables 10 months 9m
1-2 words 13 months 12 months
 SOCIAL MILESTONES

Milestone Attained Expected

Social smile 2 months 2m
Recognises mother 3 months 3m
Stranger anxiety 6 months 6m
Waves bye bye 10 months 9m
Comes when called 12 months 12m
jargon 16 months 15m
IMMUNIZATION HISTORY
At birth- BCG, opv and hep B
6 weeks- penta-1, pcv-1 and opv1 and rota virus
10weeks- penta-2 , opv-2 and pcv-2
14 weeks- penta-3, opv-3 and pcv
9months- MR and Vitamin A
16months- MR and pcv booster

IMMUNIZED AS PER AGE UPTO DATE.

SOCIO ECONOMIC STATUS
Father (28years) – auto driver – 10000/- per month
Mother (24years) – housewife- no income
Family of 4 people
Living in rented pakka house.
Common washroom for two families.
Belongs to Class 3 lower middle class according to kuppuswamy classification.
SUMMARY
18 months old girl born out of non-consanguinous marriage, 3rd in birth order
belonging to class 3 lower middle of kuppuswamy scale, developmentally normal,
immunized (NIP) upto date with calorie deficit of 595kcal/day with adequate protein
intake presented with h/o not gaining adequate weight and bowing of legs since last
6 months and h/o frequent falls while walking since last 2 months.
Probable DD
GENERAL PHYSICAL EXAMINATION
Conscious, alert
Temp- 98.4 F in axillary region
Pulse rate - 88 bpm in right radial artery, regular rhythm, normal volume, no radio-
radial or radio- femoral delay.
Respiratory rate- 26 breaths/min
Blood pressure- 90/60 mmhg taken from left arm in supine position.

- No pallor, icterus, cyanosis, clubbing, lymphadenopathy and edema.

ANTHROPOMETRY
Weight - 8kgs (1st centile)
Expected weight - 11 kg

Length- 76cms (3rd -10th centile)

Expected length - 80 cms

US- 47cms
LS – 29cms Weight age- 7 months
US: LS- 1.6 Height age- 13 months
MUAC- 13 cms Chest circumference- 46cms
HC- 44cms Arm span- 16cms
Parameter Observed Expected Inference
weight 8 kgs 11kgs 1st centile
length 76 cms 80 cms 3rd to 10th centile
head circumference 44cms 48cms 3rd to 50th centile
MUAC 13cms Normal
US:LS 47:29 1.6 Normal
Head- frontal bossing present
no softening of skull bones
Anterior and posterior fontanelle closed.
Sutures closed.
Hair- alopecia present.
Face – No facial anomalies
Oral cavity- Dentition normal
Mucosa normal
Eyes – normal
no cataract
No bitot spots
nose – normal
Ears – normal
No discharge
Wrist- widening present at wrist joint.
Abdomen- protuberant belly present
Spine- normal
No scoliosis, kyphosis
Genitalia - normal.
Chest- Harrison sulcus present
No enlargement of costochondral junctions.
Legs – Symmetrical Bowing of knees present in both limbs
SYSTEMIC EXAMINATION
PER ABDOMEN
Protubert abdomen present
Soft, non tender
No organomegaly
RESPIRATORY
Harrison sulcus present
Trachea- central
Bilateral air entry equal, no added sounds
Normal vesicular breath sounds heard
CNS EXAMINATION
Conscious, oriented
No focal neurological deficits
No signs of meningeal irritation.
CVS EXAMINATION
S1, S2 heard
No murmurs.
DIFFERENTIAL DIAGNOSIS
1. NUTRIONAL RICKETS.
2. Non Nutritional rickets.
- Vitamin D dependent rickets (VDDR) type 2
- Familial hypophosphatemic rickets
THANK YOU