Clinical Clerk

Name: Nahyan Asif

BM:23, Roll: 69, Batch: F
Bed # 12, PNPW
PARTICULARS OF THE PATIENT:

- NAME : Ripa

- AGE: 7 YEARS

- SEX: Female

- Religion: Islam

- ADDRESS: Thana: Sonargon ,Zilla: Hobhigonj

- D.O.A: 18/05/11

- D.O.E: 21/05/11

- Admission: Paediatrics Non Paying Ward

CHIEF COMPLAINTS

1) Generalised Swelling: 15 days

2) Colored urine: 14 days

3) Fever: 14 days

H/O PRESENT ILLNESS

- Ripa’s mother says that she was relatively well 15 days ago. Then on
the 7th of May her mother found a puffiness had developed in Ripa’s
face that spread throughout her body as the day progressed, running
down her abdomen to her ankles, producing a generalised swelling of
the body. No pruritus or any other symptom was associated with this
swelling

- That same night Ripa developed a fever, which was felt by hand ,but
not measured by her mother. The fever was associated with chills and
rigor, it was also associated with vomiting , abdominal discomfort and
dry cough. She also suffered from loss of appetite and had difficulty
eating. Vomitus was plenty in amount, contained undigested food
particles and occurred very frequently throughout the night. It was
projectile, but not associated with bile, blood or any foul smell.

- Ripa also complained of pain during micturition. The urine was scanty
in amount and very concentrated hence appearing deeply colored.
 - Upon seeing Ripa in this condition, her mother took her to the nearest
doctor who gave an injection and then referred her to Bangladesh
Medical College Hospital, all this occurred over a week. Most of her
symptoms subsided upon taking the medications prescribed by the
doctor at Bangladesh Medical College Hospital.

H/O PAST ILLNESS

At the age of 2 years, my patient swallowed a few rice seeds and this worried her
parents enough to take her to the doctor, the doctor prescribed some medicine
at the time which supposedly caused the seed to be excreted through her urine.
She had no health problems at any point in time due to ingestion of the seed.

BIRTH HISTORY

- Antenatal: During the first 2 months of pregnancy, the mother

frequently had headspins vomited and suffered from loss of appetite.
These symptoms subsided after taking the prescribed medicine from a
doctor; however she did not maintain a balanced diet throughout her
pregnancy due to the loss of appetite. She took the scheduled vaccine
during pregnancy and had regular ante-natal checkup.

- Natal: Birth was at normal term. Delivery took place at home under the
observation of an unqualified health worker.

- Postnatal: no jaundice, septicaemia, convulsion or delayed crying

recorded. Birth weight was not recorded.

FEEDING HISTORY

- My patient was fed breast milk for the first 2 years of her life in
addition with powdered milk that was introduced 40 days after birth.
After 2 years of age until now, she has been fed a variety of solid food
(including Khichuri) and follows the same dietary pattern as the rest of
her family.

IMMUNISATION HISTORY

- Immunisation is up to date

DEVELOPMENTAL HISTORY

- Development was normal

DRUG HISTORY
Was not on any medication prior to admission into hospital; upon admission she
has been given:

- Injection- “Furocef”: 500 mg I/V, 12 hourly

FAMILY HISTORY

- My patient lives in a joint family consisting of 11 members. Her

immediate family consists of a father, mother and an elder sister who
is 11 years old.

- Marriage was consanguinal (mother married her paternal cousin)

- The father has been living in Abu Dhabi for the past 25 years, and last
visited his family 3.5 years ago. The mother and her 2 daughters live
together with the other members in Sonargon.

- No recorded history of Ripa’s symptoms in either immediate nor

extended family of either paternal or maternal side of the family

- Father and mother have been in good health as of recent times. The
elder daughter had a cold at 7 months of age, was cured after staying
in hospital for 2 days.

SOCIO-ECONOMIC HISTORY

- Father works and mother looks after the children.