This patient report summarizes the medical history and examination of a 4-year-old girl named Alisha Sarr who presented with headaches, fatigue, joint pain, swelling of the hands and feet, jaundice, and swelling of the left hand. Her vital signs and physical exam revealed paleness, swelling of the left hand, and abdominal swelling and limited sounds. Testing found raised leukocytes in her urine. The physician requested further blood and glucose tests to determine the cause of her symptoms.

1. HEALTH SERVICES
SCOTLAND
BRANCH A
PATIENT ADMIN
GP REPORT
BAAS18052008
Name: Alisha Sarr
DOB: 18/05/2008
Age: 4 years
Symptoms: Headaches, Fatigue, Pain of the joints, Swelling of hands and feet
Signs: Jaundice, Swelling to the left hand, Weak response
Past medical History: None available
Past Surgical History: None available
Medications: Calpol (5ml twice a day)
Allergies: None known
Family History: Not available
Social History: Patient is of Angolan origin, immigrated to UK September 2012. No
previous interactions with medical service.
Vitals: BP- 100/70 Resting heart rate – 120 Weight- 28lbs Height 36inches
Physical Exam: Patient presented pale with visible swelling of the left hand, cold to the
touch. Lungs open and clear, no chest pain. Abdominal abnormalities included swelling of
upper left region and limited digestive sounds.
Testing: Urine – raised leukocytes
Outcome: Requested CB, fasting BG test
Physician
Dr A Smith
Dr A Smith | Phone: 0141 888 4444 Fax: 0141 888 4444
1 Albert Street Glasgow WWW.SCOTTISH-HEALTHCENTRE.COM