Pediatrics long case

Friday, May 4, 20120 comments


Date 5-4-2008

HISTORY

Personal History
   A male Infant named Ahmed Mohamed aged 10months from Nawag. He was admitted to TUH at 1/4/2008.Father is farmer & mother is house wife.

C/O
         1-Fever since          10 days.
         2-Cough since        7   days.
         3-Granting since    5   days.

Present History
     The condition started 10 days ago by sudden onset of fever which was high grade mainly at night. Fever was relieved by antipyretic which was given by the mother as home treatment .Cough was appeared 3 days later which was increasing at the morning. The infant received the medical treatment in form of antibiotic syrup and antitussive was described by GP doctor. However, there was no improvement and grunting appeared after 2 days. The mother sought the follow up visit by the same doctor who refered the baby to TUH. In hospital CBC,CXR were done and medical treatment in form of IV antibiotic and inhalation therapy were given. The condition was dramatically improved. Now there is no fever no grunting only mild cough is still present.
Past History

Obstetric History:
  There was no history of maternal diseases;.medications or exposure to    radiation during pregnancy.
  The labour was normal vaginal delivery at TUH. No history of perinatal anoxia.
  There was no medical problem during neonatal period.

Feeding History:
The infant was exclusively breast fed until age of 6 month. After that cow milk was given. At age of 7 month the mother introduced some solid food as potato.

Developmental History
The mother noticed that her baby supported his head at 2 months sited alone at 8 month and creped at 9 month.
He smiled at one month and recognize her at 7 month
He discriminated M M speech at 5 month and Ma Ma speech at 9 month



Vaccination History
He received all routine recommended vaccine at proper time without significant complications. The last one was measles vaccine since one month.

Past illness:
There was diarrheal disorder at the age of 5 month. He was admitted to TUH for 3 days and received IVF .
No history of surgical problem or trauma.


Family History

Parents
The mother aged 30 years not suffering from any medical problems
The father 40 aged and healthy
There is a 1st cousin parental consanguinity

Sibs
There is one sister aged 2 years healthy

Other relatives
There no apparent genetic problems among other members of the family


EXAMINATION

General Appearance:
The infant is conscious looks well without special attitude.

Anthropometric Measurement:
Head Circumference: 42 cm
Length                        :70 cm
Weight                        : 8 kg

Vital Records
Pulse (femoral) : 120 beat/minute , regular .
Temperature     : 37.5 ºC Auxiliary.
Respiratory Rate : 30 cycle /minute

Regional Examination:
 There is no pallor, jaundice , cyanosis ,eruption or purpura
 There is average subcutaneous fat and normal skin turger.
  Anterior fontanel is still open 1.5x 1.5 cm , surface is coincide with surrounding bone.
  The pupil is reactive, no nasal or ear discharge and there are 2 lower central incisors.
  There is no clubbing and no peripheral edema.


Systemic Examination

Chest:
-There is a symmetrical chest shape with equal movement on both sides.
-There is no palpable ronchi.
-There is a normal lung resonance
-Breath sound is harsh vesicular no rales can be heard

Heart
-There is no precordial bulge
-Apex is palpable in 4th ICS just outside MCL
-There is no palpable thrill
-1st & 2nd heart sounds are average on 4 auscultatory areas
-There is no gallop no murmur

Abdominal Examination
-There is no abdominal distension
-No tenderness or muscle guard
-Liver and spleen are not felt below right & left costal margin respectively.
-There is no ascites


Neurological Examinations
-Infant is conscious not apathetic with accepted mentality(development)
-Intact motor Cranial Nerves (No squint-symetrical face ,central jaw and tip of the tongue)
-There is no obvious abnormality as regard to motor system
(average muscle bulk & tone-symmetrical spontaneous movement of 4 limbs)
-Average Knee reflexes
-No signs of meningeal irritation (No neck rigidity)

NB The system involved must be taken in details

C/O of admitted case is the C/O at admission
However, in present history mention the actual symptom at the time of taken history

In Chronic diseases the C/O is that of the recent condition and primary disease must be considered as past illness

Only in case of chronic disease & there no recent illness or this visit is not a follow up one the C/O may be considered since early life
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