Sei sulla pagina 1di 5

ID:

Name: Iman feras hasan


Age: 12 year old
Address: Nablus
Date of admission:16/12/2013
Date of History taking: 17/12/2013

Informant:
Mother who seems to be reliable .

Chief Complain:
Diarrhea for 3 days .

History of present illness:


Iman feras ( who is known case of lymphoma ) was in her usual state of health till
3 days prior to admission when he started to complain of diarrhea ( 5 times per day
, large amount , watery in consistency , normal color , no smell . )
No vomiting or abdominal pain ,
This was associated with cough , rinorrhea and painful swallowing .
Also decrease in activity
no fever no chills ,.
no History of drug taking.
no history of travelling

no similar history of recurrent symptoms .


no rashes or ecomosis .
At 16/12/2013 Iman feras came to Rafedia hospital and admitted through ER to
pediatrics department .

Systemic Reviews:
1)
2)
3)
4)
5)
6)

General: no loss apetite , no weight loss


Skin:, no pigmentations, no nail or hair problems
Eyes: no redness , no change in vision acuity
ENT: no rinohrea, no snoring, no painful swallowing, no ear discharge
CVS: no edema , no chest pain .
Neuromuscular: not irritable, no convulsions, no joints swellings or pain .

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

9. Drug history: chemotherapy


10.Allergy : no known allergons
11.Immunization: full immunized, no complications .
12.No blood transfusion .

Family History:
Healthy parents
No abortion
No similar HX in her sister

Social History:
non consanguineous

He lives in 2nd floor, well ventilated house


2 siblings .
non smoking
moderate economic status
No domestic animals

Physical Examination:
1. General appearance: patient looks ill , not comfortable, oriented to time
person and place , pallor ,dry mucous membrane ,dry lipd , not tacypnic ,

normal skin turgor , no cyanosis, no jaundice, delay capillary refill , canula


inserted into her right hand .
2. Vital signs:
Temp: 38 C
Pulse: 100/min
RR: 22/min
BP: 100/60
3. Growth parameters:
Weight: 30 kg
Length: 150 cm
4. Eyes: pallor, no jaundice
5. ENT: ears were not examined by otoscope but by inspection there was no
discharge, no redness, and no tenderness. Not congested tonsils
6. Respiratory system:
Inspection: no subcostal retraction, no chest deformities , no visible
pulsation, no scars, no tracheal tug, no nasal flaring
Palpation: trachea is centralized
Percussion: ---- Auscultation:, normal vesicular breathing sound .
7. CVS:
Inspection: no chest deformities, no visible pulsation, no scars
Palpation: no thrills, no heaves, PMI (5th intercostal space MCL)
Auscultation: tachycardia, no murmers, no added sounds
Pulse: 100/min regular, weak volume () .
Capillary refill < 4 seconds
8. GI system:
Inspection: abdomen scaphiod, umbilicus centrally located, normally
inverted, no fullness and echomosis on flanks, no pigmentations, no
scars, no visible masses, no dilated veins, no jaundice
Palpation: superficial palpation revealed no tenderness, no masses.
Deep palpation revealed no tenderness , no masses
Percussion: Tympanic sound all over abdomen
Auscultation: normal bowel sound
9. Neurological examination :
Fully conscious and alert

Crainial nerve ; normal , no abnormality detected .


Normal tone , power and reflexes ()
Negative signs of meningeal irritation

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 .