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Informant:
Mother who seems to be reliable .
Chief Complain:
Diarrhea for 3 days .
Systemic Reviews:
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Past History:
1. Antenatal: Good health of mother during pregnancy, she visited pregnancy
clinics regularly, U/S done and was normal, no complications during
pregnancy .
2. Neonatal: he is a product of, normal vaginal delivery GA 9 months, 4.1 kg
3. Postnatal: baby pink color, no cyanosis, no jaundice, no NICU admission
4. Growth and development:
He walked at 1.4 year
Begins to speak sentences at 3 years
He is toilet trained at 3 years
Reactive with others .
5. Nutrition:
Breast fed until age of 2 year
Introduction of solid food at age of 6 months
6. He is now eating house hold .
7. Past medical hx : lymphoma around the spine causing hemiplagia
8. Past surgery : free
Family History:
Healthy parents
No abortion
No similar HX in her sister
Social History:
non consanguineous
Physical Examination:
1. General appearance: patient looks ill , not comfortable, oriented to time
person and place , pallor ,dry mucous membrane ,dry lipd , not tacypnic ,
Summary:
Iman feras a 12 year old patient came to hospital complained of diarrhea for 2
days ,, physical examination revealed signs of moderate dehydration .
DD :
Gastroenteritis .