Comment by Morgan, Dorothy Tali Do not forget to include a runniLynellBull52
Comment by Morgan, Dorothy Tali: Do not forget to include a running head to follow APA guidelines
Health History
Yensi Aguilar
Benjamin Leon School of nursing
NUR1060C: Adult Health Assessment
Professor Dorothy Morgan
April 7, 2021
Health History
Identifying data
Date of history: 28/02/2021
Examiner: Yensi Aguilar
Name: L.P.
Address: 3403 SW 6h Street
Phone Number: 786-597-3071
Age:46
Sex: Female
Race: White
Place of Birth: Honduras
Marital Status: Married
Significant Other: Husband
Occupation: Teacher
Religion: Christian
Primary Language: Spanish
Secondary Language: English
Source of referral: The patient found the hospital’s address on the internet
Source of history: Documents with the patient’s health history gave information concerning the patient. The patient also talked concerning her health status.
Reliability: Currently, the patient seems to have a stable mental and physical state.
Chief Complaints/Reasons for Visit: According to the patient, she started experiencing high fever, blood-stained sputum, night sweats, coughing, and weight loss.
Present Illness
Time of onset: according to the patient, she started experiencing symptoms two weeks ago.
Type of onset: The patient says that she started by occasionally sweating, mild cough, headache, and pain in the abdomen area. Over time, these conditions became severe.
Original Source: The patient complains of pain in her chest and respiratory tract.
Severity: During the day, the patient does not feel many discomforts, but it becomes worse at night due to lower temperatures. Hence, the condition does not deter the patient from executing tasks during the day. The severity of her state is at 5 out of 10 on a 0-to-10-point scale.
Radiation: At night, the patient feels severe pain throughout her chest region
Time Relationship: At first, this condition was still developing and was easy to handle. However, it has evolved and has gotten worse.
Duration: It has been two weeks since the patient started experiencing the symptoms.
Association: The symptoms experienced by the patient are similar to those of flu.
Source of Relief: According to the patient, she feels better when resting after doing some light physical exercise.
Source of Aggravation: The symptoms become worse during the night. Again, exposure to allergens such as dust or cold increases the symptom’s severity.
Past History
General State of Health: The patient’s general condition is fair, considering she is suffering from a chronic illness.
Childhood Illnesses: She suffered from smallpox and measles as a child
Adult Illnesses: Hypertension, Anemia, and asthma
Psychiatric Illnesses: She has experienced mild depression in the past
Accidents and Injuries: Never had an accident or injuries
Operations: The patient denies any surgical operations
Hospitalizations: After visiting the hospital, the patient got an admission to the Jackson Hospital for one week to undergo treatment for asthma and hyper ...
Minu Akter, a 1-year-old female, presented with fever, cough, and breathlessness. Examination found tachycardia, tachypnea, and a continuous murmur. Investigations confirmed moderate patent ductus arteriosus (PDA) with heart failure and pneumonia. She was treated with antibiotics, diuretics, and angiotensin-converting enzyme inhibitors, and her symptoms improved. An echocardiogram showed the PDA, and it was successfully closed with a device during catheterization. She was discharged with advice to follow up in one month.
It is a case study report of mucopolysaccharidosis, I did when I was posted in Kanti Children's hospital
Prepared by:
Rashmi Regmi
B. Sc Nursing
Manmohan Memorial Institute of Health Sciences
The 85-year-old male patient presented with progressive forgetfulness, weight loss, and depressed mood over the past year since his wife's death. His daughter observed a decline in his ability to recall recent events, directions, and names. Alzheimer's disease is the primary consideration given his age and symptoms consistent with typical memory loss and cognitive decline seen in Alzheimer's. Differential diagnoses considered include delirium, depression, and hypothyroidism but were deemed less likely based on aspects of his history and presentation that did not fully match these conditions.
The 85-year-old male patient presented with progressive forgetfulness, weight loss, and depressed mood over the past year since his wife's death. His daughter observed deterioration in his memory, concentration, and ability to carry on conversations. Alzheimer's disease is the primary consideration given his age and symptom progression. Differential diagnoses considered include delirium, depression, and hypothyroidism but were deemed less likely based on aspects of his clinical presentation and history.
Pediatric Neurology. A presentation on stroke in pediatric casessuser3fc2dd
A 7-year-old boy presented with 5 days of fever and 2 days of right-sided weakness. On examination, he had right arm and leg weakness with difficulty speaking but was otherwise normal. Investigations showed microcytic anemia, elevated white blood cells, and a turbid CSF with elevated proteins and white blood cells suggestive of pyogenic meningitis. CT scan showed mild brain edema. He was diagnosed with pyogenic meningitis.
Comment by Morgan, Dorothy Tali Do not forget to include a runniLynellBull52
Comment by Morgan, Dorothy Tali: Do not forget to include a running head to follow APA guidelines
Health History
Yensi Aguilar
Benjamin Leon School of nursing
NUR1060C: Adult Health Assessment
Professor Dorothy Morgan
April 7, 2021
Health History
Identifying data
Date of history: 28/02/2021
Examiner: Yensi Aguilar
Name: L.P.
Address: 3403 SW 6h Street
Phone Number: 786-597-3071
Age:46
Sex: Female
Race: White
Place of Birth: Honduras
Marital Status: Married
Significant Other: Husband
Occupation: Teacher
Religion: Christian
Primary Language: Spanish
Secondary Language: English
Source of referral: The patient found the hospital’s address on the internet
Source of history: Documents with the patient’s health history gave information concerning the patient. The patient also talked concerning her health status.
Reliability: Currently, the patient seems to have a stable mental and physical state.
Chief Complaints/Reasons for Visit: According to the patient, she started experiencing high fever, blood-stained sputum, night sweats, coughing, and weight loss.
Present Illness
Time of onset: according to the patient, she started experiencing symptoms two weeks ago.
Type of onset: The patient says that she started by occasionally sweating, mild cough, headache, and pain in the abdomen area. Over time, these conditions became severe.
Original Source: The patient complains of pain in her chest and respiratory tract.
Severity: During the day, the patient does not feel many discomforts, but it becomes worse at night due to lower temperatures. Hence, the condition does not deter the patient from executing tasks during the day. The severity of her state is at 5 out of 10 on a 0-to-10-point scale.
Radiation: At night, the patient feels severe pain throughout her chest region
Time Relationship: At first, this condition was still developing and was easy to handle. However, it has evolved and has gotten worse.
Duration: It has been two weeks since the patient started experiencing the symptoms.
Association: The symptoms experienced by the patient are similar to those of flu.
Source of Relief: According to the patient, she feels better when resting after doing some light physical exercise.
Source of Aggravation: The symptoms become worse during the night. Again, exposure to allergens such as dust or cold increases the symptom’s severity.
Past History
General State of Health: The patient’s general condition is fair, considering she is suffering from a chronic illness.
Childhood Illnesses: She suffered from smallpox and measles as a child
Adult Illnesses: Hypertension, Anemia, and asthma
Psychiatric Illnesses: She has experienced mild depression in the past
Accidents and Injuries: Never had an accident or injuries
Operations: The patient denies any surgical operations
Hospitalizations: After visiting the hospital, the patient got an admission to the Jackson Hospital for one week to undergo treatment for asthma and hyper ...
Minu Akter, a 1-year-old female, presented with fever, cough, and breathlessness. Examination found tachycardia, tachypnea, and a continuous murmur. Investigations confirmed moderate patent ductus arteriosus (PDA) with heart failure and pneumonia. She was treated with antibiotics, diuretics, and angiotensin-converting enzyme inhibitors, and her symptoms improved. An echocardiogram showed the PDA, and it was successfully closed with a device during catheterization. She was discharged with advice to follow up in one month.
It is a case study report of mucopolysaccharidosis, I did when I was posted in Kanti Children's hospital
Prepared by:
Rashmi Regmi
B. Sc Nursing
Manmohan Memorial Institute of Health Sciences
The 85-year-old male patient presented with progressive forgetfulness, weight loss, and depressed mood over the past year since his wife's death. His daughter observed a decline in his ability to recall recent events, directions, and names. Alzheimer's disease is the primary consideration given his age and symptoms consistent with typical memory loss and cognitive decline seen in Alzheimer's. Differential diagnoses considered include delirium, depression, and hypothyroidism but were deemed less likely based on aspects of his history and presentation that did not fully match these conditions.
The 85-year-old male patient presented with progressive forgetfulness, weight loss, and depressed mood over the past year since his wife's death. His daughter observed deterioration in his memory, concentration, and ability to carry on conversations. Alzheimer's disease is the primary consideration given his age and symptom progression. Differential diagnoses considered include delirium, depression, and hypothyroidism but were deemed less likely based on aspects of his clinical presentation and history.
Pediatric Neurology. A presentation on stroke in pediatric casessuser3fc2dd
A 7-year-old boy presented with 5 days of fever and 2 days of right-sided weakness. On examination, he had right arm and leg weakness with difficulty speaking but was otherwise normal. Investigations showed microcytic anemia, elevated white blood cells, and a turbid CSF with elevated proteins and white blood cells suggestive of pyogenic meningitis. CT scan showed mild brain edema. He was diagnosed with pyogenic meningitis.
- The patient Laam, a 9 month old boy, presented with recurrent seizures for 1 month with delayed developmental milestones.
- His neurological exam and investigations including EEG and CT brain were suggestive of West Syndrome with bilateral cerebral atrophy possibly due to birth asphyxia.
- He was started on ACTH and antihypertensive treatment. Follow up showed improved seizure control but persistent hypertension requiring dose adjustment. Eye evaluation found pale optic discs and chorioretinal changes.
Sufiah, a 13-month-old Cambodian girl, was referred to the hospital with generalized swelling, especially around her eyes and abdomen. Physical examination revealed generalized edema with fluid in the abdomen. Laboratory tests showed protein in her urine and low albumin levels. She was diagnosed with idiopathic nephrotic syndrome based on her symptoms and test results.
1) Sufiah, a 13-month-old Cambodian girl, was referred to the hospital with generalized swelling of the body, including around the eyes and abdomen.
2) She had a history of fever and coughing for the past 10 days. Swelling began 3 days prior to admission and worsened.
3) At the hospital, examination found generalized edema, distended abdomen with fluid, and periorbital swelling. Her development was age-appropriate.
1) Sufiah, a 13-month-old Cambodian girl, was referred to the hospital with generalized swelling of the body, including around the eyes and abdomen.
2) She had a history of fever and coughing for the past 10 days. Swelling began 3 days prior to admission and worsened.
3) At the hospital, examination found generalized edema, distended abdomen with fluid, and periorbital swelling. Her development was age-appropriate.
This case presentation summarizes the medical history and examination of a 1 year old female patient presenting with fever and cough for 4 days. On examination, the patient had normal vital signs with bilateral crepitations on lung examination. Chest X-ray and lab tests were performed. Differential diagnoses of acute bronchiolitis and pneumonia were considered. The patient was treated with nebulizers, antibiotics, antipyretics and IV fluids. Acute bronchiolitis was concluded as the likely diagnosis based on symptoms, examination and test results.
The document describes a case of enteric fever in a 48-year-old male patient who presented with 10 days of fever, abdominal pain, and diarrhea. On examination, the patient had a fever of 102.8°F and central tongue coating. Testing showed a positive Typhidot IgM result. The patient was diagnosed with enteric fever and treated with intravenous ceftriaxone for 7 days, with improvement of symptoms by day 4 of treatment. The document then discusses the pathogenesis, complications, and management of enteric fever.
The document describes a case of enteric fever in a 48-year-old male patient who presented with 10 days of fever, abdominal pain, and diarrhea. On examination, the patient had a fever of 102.8°F and central tongue coating. Testing showed a positive Typhidot IgM result. The patient was diagnosed with enteric fever and treated with intravenous ceftriaxone for 7 days, with improvement of symptoms by day 4 of treatment. The document then discusses the pathogenesis, complications, and differential diagnosis of enteric fever.
This document provides details of a clinical meeting presentation about a 2 year 4 month old boy named Saif who was admitted with a 2.5 month history of fever and 2 month history of chest pain and breathing difficulty. On examination, he was mildly pale with enlarged lymph nodes and hepatomegaly. Imaging showed a left-sided pleural effusion. A biopsy revealed T-cell lymphoblastic lymphoma. He received supportive treatment and chemotherapy according to the BFM-95 protocol. On follow up, he was improving with continued chemotherapy and a repeat chest x-ray showed improvement in the pleural effusion.
This document provides details from a clinical meeting regarding a patient named Rafin. Rafin is a 4 year old male who has been experiencing seizures since age 1. He also has delays in development including lack of neck control or ability to sit. The document describes Rafin's history, examination, assessments, diagnoses of spastic quadriplegic cerebral palsy with microcephaly and global developmental delays, and proposed management including nutrition, medications, therapies and follow up.
A 14-year-old boy presented with difficulty breathing, facial swelling, swelling of both feet, and chest pain for two days. He had a history of a similar episode 8 months prior where he was diagnosed with a heart condition. On examination, he had an irregularly irregular pulse, low blood pressure, visible apex beat, and grade V pansystolic murmurs in the mitral, tricuspid, and pulmonary areas, suggestive of chronic rheumatic heart disease with mitral regurgitation and left ventricular hypertrophy.
This document summarizes a case presentation of a 4-year-old boy named MSR who was admitted to the hospital due to severe diarrhea, fever, and vomiting. He developed diarrhea 2 days prior along with a fever and vomiting on the day of admission. Upon examination at the hospital, his vital signs and physical examination were normal except for gastrointestinal findings. His condition and symptoms are presented in detail.
This document summarizes a case presentation of a 4-year-old boy named MSR who was admitted to the hospital due to severe diarrhea, fever, and vomiting. He developed diarrhea and loss of appetite 2 days before admission. On the day of admission he developed a high fever of 39.2 degrees Celsius and vomiting. Upon examination at the hospital, he appeared stable with no abnormalities found other than symptoms related to his gastrointestinal issues.
KA, a 7-month-old Malay boy, was admitted to the hospital due to shortness of breath, coughing, and vomiting. On examination, he showed signs of respiratory distress including rapid breathing and recession of the ribs. Auscultation revealed widespread crackles and wheezes throughout both lungs. A provisional diagnosis of pneumonia was made, with bronchiolitis and asthma considered as differentials. Blood tests and renal function were normal.
LN is a 9-year old girl presenting with a 3 month history of productive cough and recent hemoptysis. She reports fever, intermittent dyspnea, chest pain and significant weight loss. On examination, she appears thin and in respiratory distress. Her lungs show decreased air entry and absent breath sounds on the left lower lobe. She is being evaluated for potential causes such as pulmonary TB, pneumonia, or a lung mass. Further testing is needed to make a diagnosis.
Clinical Documentation Template
Subjective
Chief Complaint: 52 year old male present for three month follow and labs check.
HPI: A 52-year old male with PMH of Hyperlipidemia diabetes presents to the clinic for three month follow up. Patient complained of polyuria, polydipsia and polyphasia. Patient is presently taking plavix and sexagliptin. Patient denies any chest pain, fever and chills.
ROS
General: lost 15lbs in last one month, admit weakness, fatigue. Denies depression, suicide throught.
Skin: no rashes, no open wound..
Head: Denies headache, head injury, dizziness.
Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred
vision, or blindness.
Ears: no hearing change, tinnitus, infection, discharge.
Nose/Sinus: negative for Rhinohea, No sinus pain or epistaxis.
Throat: No bleeding gums, dentures, sore tongue,dry mouth. Last dental exam 4 months ago.
Neck: No lumps, swollen glands, goiter, pain, or neck stiffness.
Neuro: experience syncope once a week, denies seizures, weakness, paralysis, numbness/tingling, tremors, or involuntary movements.
Pulmonary: negative hemoptysis, dyspnea, wheezing,pleuritic pain
Peripheral vascular: no claudication, leg cramps, varicose veins, history of blood clots,
abdominal, flank, or back pain. Pain in arms or legs. Intermittent claudication, cold, numbness,
pallor legs. Swelling in calves, legs, or feet. No color change in fingertips or toes in cold weather.
Swelling with redness or tenderness.
MS: no muscle, joint pain, or joint stiffness.
GI: No changes in appetite, excessive hunger or thirst, jaundice, N/V, dysphagia, heartburn, pain,
belching/flatulence, change in bowel habits, hematochezia, melena, constipation, diarrhea, food
intolerance, indigestion, nausea, vomiting, early fullness, odynophagia.
GU: No suprapubic pain, dysuria, urgency, frequency, hesitancy, decreased stream, polyuria,
nocturia, incontinence, hematuria, kidney, or flank pain, ureteral colic, hemorrhoids.
O:
Past Medical History: Hyperlipidemia, diabetes
Surgeries: Appendectomy, 2000
Hospitalizations: 2000 (for appendectomy)
Allergies: NKDA
Food, drug, environmental: None
Medications: Plavix 75 mg daily (prescribed by his PCP in INDIA as a prophylaxis to prevent Heart attack. We use Aspirin 81 mg here in USA)
Sexagliptin 5 mg daily
Family History: Gout (Father)
Diabetes (Mother)
.
Social History: Denies tobacco/e-cigarette and alcohol use.
Objective
Vital Signs: Temp 98.2 BP 128/90 Pulse 64 RR 18 Pain 0 Height 5’ 8” Weight 140 lb BMI 21.3 SpO2 97% @ RA
Labs: Lipid Panel
Cholesterol 272 mg/dl
Triglyceride 175 mg/dl
HDL 28 mg/dl
LDL 135 mg/dl
HgA1c 9.8%
Physical Exam:
HEENT:
Head: hair normal texture and distribution, no lumps/bumps/lesions noted to scalp. Scalp/skull non-tender with palpation. Skull normocephalic/atraumati.
This document presents the case of a 16-year-old male who was admitted for syncope and urticaria. His symptoms began 16 hours prior with chest pain, weakness, and two episodes of syncope. At the emergency room, he was found to have hypertension, tachycardia, wheals on his face and chest, and slurred speech. He was diagnosed with anaphylaxis and referred to the pediatric intensive care unit for further evaluation and management. His history was significant for prior episodes of asthma, food allergies, and a recent diagnosis of cold urticaria. On examination, he displayed signs of respiratory distress, urticaria on his chest and abdomen, and decreased motor strength.
An 18-year-old male presented with one week of high fever followed by three days of jaundice, vomiting, and abdominal pain, and six hours of unconsciousness. Physical examination found jaundice and hepatomegaly. Laboratory results showed elevated liver enzymes and hepatitis C positivity. The patient was diagnosed with acute fulminant viral hepatitis based on laboratory findings and treated supportively.
The patient, a 50-year-old female, presented with a 2-week history of abdominal pain and 6-day history of difficulty breathing. On examination, she had tender hepatomegaly, shifting dullness, and fine crackles in her lungs. Her vital signs showed a pulse of 92 bpm, respiratory rate of 23 breaths/min, and blood pressure of 100/60 mmHg. She was diagnosed with congestive cardiac failure secondary to hypertension based on her history and examination findings.
SOAP NOTE
Name:
N.C
Date:
10/26/2020
Time:
09.30 h
Age:
5-year-old
Sex:
M
CC:
"I have sore throat"
HPI:
A 5 y/o Hispanic male presents to the clinic complaining of sore throat that started 3 days ago. Describes that occasionally feels like “piercing or burning” pain that it is constant. Also, that is very painful to swallow. Mother states patient developed cold symptoms (cough, sneezing) about 5 days ago, sore throat started 3 days ago, and fever of 101.5 F began 24h ago. Patient added that the pain varies in intensity, rated anywhere from 8 to 9 on a Wong-Baker scale when eating or drinking, but at this moment rated his pain at 5. Reports that pain is not radiating to any surrounded area and “is better when drinking sips of a cold liquids like water or Kool-Aid or takes Ice cream”. Mother also states that fever somehow is relieved by rest and Tylenol. Confirms that his appetite has decreased in the last 3 days.
Medications:
Tylenol OTC PO PRN
PMH
Allergies: NKDA
Medication Intolerances: None
Chronic Illnesses/Major traumas: None
Hospitalizations/Surgeries: None
Immunizations:
- According to CDC for his age group, he is up to date with the following vaccines
• Influenza 2019
• Tdap 5th dose
• MMR 2nd dose
• Polio IVP 4th dose
• Chickenpox (Varicella) 2nd dose
Family History:
Mother: Alive – no significant medical history
Father: Alive - HTN
Sister: 8 years old healthy
Brother: 2 days old healthy
Social History
Lives with both parents and siblings. Appears comfortable and happy with mother in the room. Neither parents smoke. Patient began kindergarten this year at local public school.
General
Patient reports sore throat, but overall healthy, appropriate weight and height for age, usually very active but mostly lying around the past few days per mom.
Cardiovascular
Denies chest pain or palpitations.
Skin
Denies rash, inflammation, pain, tenderness, or skin lesion.
Respiratory
Denies any cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB exposure or symptoms per mom, or SOB.
Eyes
Denies use of corrective lenses or glasses, blurred vision, or visual changes of any kind.
ENT
Denies ear pain, hearing loss, ringing in ears, discharge. Reports no sinus problems, or nose bleeding. Complains of sore throat and aggravating pain when swallowing. Goes to dentist every 6 months per mom.
Gastrointestinal
Denies diarrhea, abdominal pain, or heartburn. He had his last bowel movement this morning and goes at least once a day.
Genitourinary
Denies urgency, frequency or burning and pain with urination. Reports no hematuria or change in color of urine. Denies penile pain.
Musculoskeletal
Denies back pain, joint swelling, stiffness, or muscle pain.
Heme/Lymph/Endo
Denies fatigue. Mother states swollen/tender cervical lymph nodes. Patient is appropriate size and weight for his age.
Neurological
Denies any syncope, seizures, transient paralysis, paresthesi.
3 month old baby Fathima Sampra presented with cough for 7 days. The cough was worse when lying down and caused waking at night. On examination, the baby had increased respiratory rate and bilateral crepitation at the lung bases. Differential diagnoses included bronchiolitis, bronchial asthma, and pneumonia. Treatment involved nebulized ipratropium and hypertonic saline, along with saline nasal drops. Oxygen supplementation was not needed as the baby's saturation was normal.
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
Histololgy of Female Reproductive System.pptxAyeshaZaid1
Dive into an in-depth exploration of the histological structure of female reproductive system with this comprehensive lecture. Presented by Dr. Ayesha Irfan, Assistant Professor of Anatomy, this presentation covers the Gross anatomy and functional histology of the female reproductive organs. Ideal for students, educators, and anyone interested in medical science, this lecture provides clear explanations, detailed diagrams, and valuable insights into female reproductive system. Enhance your knowledge and understanding of this essential aspect of human biology.
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- The patient Laam, a 9 month old boy, presented with recurrent seizures for 1 month with delayed developmental milestones.
- His neurological exam and investigations including EEG and CT brain were suggestive of West Syndrome with bilateral cerebral atrophy possibly due to birth asphyxia.
- He was started on ACTH and antihypertensive treatment. Follow up showed improved seizure control but persistent hypertension requiring dose adjustment. Eye evaluation found pale optic discs and chorioretinal changes.
Sufiah, a 13-month-old Cambodian girl, was referred to the hospital with generalized swelling, especially around her eyes and abdomen. Physical examination revealed generalized edema with fluid in the abdomen. Laboratory tests showed protein in her urine and low albumin levels. She was diagnosed with idiopathic nephrotic syndrome based on her symptoms and test results.
1) Sufiah, a 13-month-old Cambodian girl, was referred to the hospital with generalized swelling of the body, including around the eyes and abdomen.
2) She had a history of fever and coughing for the past 10 days. Swelling began 3 days prior to admission and worsened.
3) At the hospital, examination found generalized edema, distended abdomen with fluid, and periorbital swelling. Her development was age-appropriate.
1) Sufiah, a 13-month-old Cambodian girl, was referred to the hospital with generalized swelling of the body, including around the eyes and abdomen.
2) She had a history of fever and coughing for the past 10 days. Swelling began 3 days prior to admission and worsened.
3) At the hospital, examination found generalized edema, distended abdomen with fluid, and periorbital swelling. Her development was age-appropriate.
This case presentation summarizes the medical history and examination of a 1 year old female patient presenting with fever and cough for 4 days. On examination, the patient had normal vital signs with bilateral crepitations on lung examination. Chest X-ray and lab tests were performed. Differential diagnoses of acute bronchiolitis and pneumonia were considered. The patient was treated with nebulizers, antibiotics, antipyretics and IV fluids. Acute bronchiolitis was concluded as the likely diagnosis based on symptoms, examination and test results.
The document describes a case of enteric fever in a 48-year-old male patient who presented with 10 days of fever, abdominal pain, and diarrhea. On examination, the patient had a fever of 102.8°F and central tongue coating. Testing showed a positive Typhidot IgM result. The patient was diagnosed with enteric fever and treated with intravenous ceftriaxone for 7 days, with improvement of symptoms by day 4 of treatment. The document then discusses the pathogenesis, complications, and management of enteric fever.
The document describes a case of enteric fever in a 48-year-old male patient who presented with 10 days of fever, abdominal pain, and diarrhea. On examination, the patient had a fever of 102.8°F and central tongue coating. Testing showed a positive Typhidot IgM result. The patient was diagnosed with enteric fever and treated with intravenous ceftriaxone for 7 days, with improvement of symptoms by day 4 of treatment. The document then discusses the pathogenesis, complications, and differential diagnosis of enteric fever.
This document provides details of a clinical meeting presentation about a 2 year 4 month old boy named Saif who was admitted with a 2.5 month history of fever and 2 month history of chest pain and breathing difficulty. On examination, he was mildly pale with enlarged lymph nodes and hepatomegaly. Imaging showed a left-sided pleural effusion. A biopsy revealed T-cell lymphoblastic lymphoma. He received supportive treatment and chemotherapy according to the BFM-95 protocol. On follow up, he was improving with continued chemotherapy and a repeat chest x-ray showed improvement in the pleural effusion.
This document provides details from a clinical meeting regarding a patient named Rafin. Rafin is a 4 year old male who has been experiencing seizures since age 1. He also has delays in development including lack of neck control or ability to sit. The document describes Rafin's history, examination, assessments, diagnoses of spastic quadriplegic cerebral palsy with microcephaly and global developmental delays, and proposed management including nutrition, medications, therapies and follow up.
A 14-year-old boy presented with difficulty breathing, facial swelling, swelling of both feet, and chest pain for two days. He had a history of a similar episode 8 months prior where he was diagnosed with a heart condition. On examination, he had an irregularly irregular pulse, low blood pressure, visible apex beat, and grade V pansystolic murmurs in the mitral, tricuspid, and pulmonary areas, suggestive of chronic rheumatic heart disease with mitral regurgitation and left ventricular hypertrophy.
This document summarizes a case presentation of a 4-year-old boy named MSR who was admitted to the hospital due to severe diarrhea, fever, and vomiting. He developed diarrhea 2 days prior along with a fever and vomiting on the day of admission. Upon examination at the hospital, his vital signs and physical examination were normal except for gastrointestinal findings. His condition and symptoms are presented in detail.
This document summarizes a case presentation of a 4-year-old boy named MSR who was admitted to the hospital due to severe diarrhea, fever, and vomiting. He developed diarrhea and loss of appetite 2 days before admission. On the day of admission he developed a high fever of 39.2 degrees Celsius and vomiting. Upon examination at the hospital, he appeared stable with no abnormalities found other than symptoms related to his gastrointestinal issues.
KA, a 7-month-old Malay boy, was admitted to the hospital due to shortness of breath, coughing, and vomiting. On examination, he showed signs of respiratory distress including rapid breathing and recession of the ribs. Auscultation revealed widespread crackles and wheezes throughout both lungs. A provisional diagnosis of pneumonia was made, with bronchiolitis and asthma considered as differentials. Blood tests and renal function were normal.
LN is a 9-year old girl presenting with a 3 month history of productive cough and recent hemoptysis. She reports fever, intermittent dyspnea, chest pain and significant weight loss. On examination, she appears thin and in respiratory distress. Her lungs show decreased air entry and absent breath sounds on the left lower lobe. She is being evaluated for potential causes such as pulmonary TB, pneumonia, or a lung mass. Further testing is needed to make a diagnosis.
Clinical Documentation Template
Subjective
Chief Complaint: 52 year old male present for three month follow and labs check.
HPI: A 52-year old male with PMH of Hyperlipidemia diabetes presents to the clinic for three month follow up. Patient complained of polyuria, polydipsia and polyphasia. Patient is presently taking plavix and sexagliptin. Patient denies any chest pain, fever and chills.
ROS
General: lost 15lbs in last one month, admit weakness, fatigue. Denies depression, suicide throught.
Skin: no rashes, no open wound..
Head: Denies headache, head injury, dizziness.
Eyes: no vision change, corrective lenses, pain redness, excessive tearing, double vision, blurred
vision, or blindness.
Ears: no hearing change, tinnitus, infection, discharge.
Nose/Sinus: negative for Rhinohea, No sinus pain or epistaxis.
Throat: No bleeding gums, dentures, sore tongue,dry mouth. Last dental exam 4 months ago.
Neck: No lumps, swollen glands, goiter, pain, or neck stiffness.
Neuro: experience syncope once a week, denies seizures, weakness, paralysis, numbness/tingling, tremors, or involuntary movements.
Pulmonary: negative hemoptysis, dyspnea, wheezing,pleuritic pain
Peripheral vascular: no claudication, leg cramps, varicose veins, history of blood clots,
abdominal, flank, or back pain. Pain in arms or legs. Intermittent claudication, cold, numbness,
pallor legs. Swelling in calves, legs, or feet. No color change in fingertips or toes in cold weather.
Swelling with redness or tenderness.
MS: no muscle, joint pain, or joint stiffness.
GI: No changes in appetite, excessive hunger or thirst, jaundice, N/V, dysphagia, heartburn, pain,
belching/flatulence, change in bowel habits, hematochezia, melena, constipation, diarrhea, food
intolerance, indigestion, nausea, vomiting, early fullness, odynophagia.
GU: No suprapubic pain, dysuria, urgency, frequency, hesitancy, decreased stream, polyuria,
nocturia, incontinence, hematuria, kidney, or flank pain, ureteral colic, hemorrhoids.
O:
Past Medical History: Hyperlipidemia, diabetes
Surgeries: Appendectomy, 2000
Hospitalizations: 2000 (for appendectomy)
Allergies: NKDA
Food, drug, environmental: None
Medications: Plavix 75 mg daily (prescribed by his PCP in INDIA as a prophylaxis to prevent Heart attack. We use Aspirin 81 mg here in USA)
Sexagliptin 5 mg daily
Family History: Gout (Father)
Diabetes (Mother)
.
Social History: Denies tobacco/e-cigarette and alcohol use.
Objective
Vital Signs: Temp 98.2 BP 128/90 Pulse 64 RR 18 Pain 0 Height 5’ 8” Weight 140 lb BMI 21.3 SpO2 97% @ RA
Labs: Lipid Panel
Cholesterol 272 mg/dl
Triglyceride 175 mg/dl
HDL 28 mg/dl
LDL 135 mg/dl
HgA1c 9.8%
Physical Exam:
HEENT:
Head: hair normal texture and distribution, no lumps/bumps/lesions noted to scalp. Scalp/skull non-tender with palpation. Skull normocephalic/atraumati.
This document presents the case of a 16-year-old male who was admitted for syncope and urticaria. His symptoms began 16 hours prior with chest pain, weakness, and two episodes of syncope. At the emergency room, he was found to have hypertension, tachycardia, wheals on his face and chest, and slurred speech. He was diagnosed with anaphylaxis and referred to the pediatric intensive care unit for further evaluation and management. His history was significant for prior episodes of asthma, food allergies, and a recent diagnosis of cold urticaria. On examination, he displayed signs of respiratory distress, urticaria on his chest and abdomen, and decreased motor strength.
An 18-year-old male presented with one week of high fever followed by three days of jaundice, vomiting, and abdominal pain, and six hours of unconsciousness. Physical examination found jaundice and hepatomegaly. Laboratory results showed elevated liver enzymes and hepatitis C positivity. The patient was diagnosed with acute fulminant viral hepatitis based on laboratory findings and treated supportively.
The patient, a 50-year-old female, presented with a 2-week history of abdominal pain and 6-day history of difficulty breathing. On examination, she had tender hepatomegaly, shifting dullness, and fine crackles in her lungs. Her vital signs showed a pulse of 92 bpm, respiratory rate of 23 breaths/min, and blood pressure of 100/60 mmHg. She was diagnosed with congestive cardiac failure secondary to hypertension based on her history and examination findings.
SOAP NOTE
Name:
N.C
Date:
10/26/2020
Time:
09.30 h
Age:
5-year-old
Sex:
M
CC:
"I have sore throat"
HPI:
A 5 y/o Hispanic male presents to the clinic complaining of sore throat that started 3 days ago. Describes that occasionally feels like “piercing or burning” pain that it is constant. Also, that is very painful to swallow. Mother states patient developed cold symptoms (cough, sneezing) about 5 days ago, sore throat started 3 days ago, and fever of 101.5 F began 24h ago. Patient added that the pain varies in intensity, rated anywhere from 8 to 9 on a Wong-Baker scale when eating or drinking, but at this moment rated his pain at 5. Reports that pain is not radiating to any surrounded area and “is better when drinking sips of a cold liquids like water or Kool-Aid or takes Ice cream”. Mother also states that fever somehow is relieved by rest and Tylenol. Confirms that his appetite has decreased in the last 3 days.
Medications:
Tylenol OTC PO PRN
PMH
Allergies: NKDA
Medication Intolerances: None
Chronic Illnesses/Major traumas: None
Hospitalizations/Surgeries: None
Immunizations:
- According to CDC for his age group, he is up to date with the following vaccines
• Influenza 2019
• Tdap 5th dose
• MMR 2nd dose
• Polio IVP 4th dose
• Chickenpox (Varicella) 2nd dose
Family History:
Mother: Alive – no significant medical history
Father: Alive - HTN
Sister: 8 years old healthy
Brother: 2 days old healthy
Social History
Lives with both parents and siblings. Appears comfortable and happy with mother in the room. Neither parents smoke. Patient began kindergarten this year at local public school.
General
Patient reports sore throat, but overall healthy, appropriate weight and height for age, usually very active but mostly lying around the past few days per mom.
Cardiovascular
Denies chest pain or palpitations.
Skin
Denies rash, inflammation, pain, tenderness, or skin lesion.
Respiratory
Denies any cough, wheezing, hemoptysis, dyspnea, pneumonia hx, TB exposure or symptoms per mom, or SOB.
Eyes
Denies use of corrective lenses or glasses, blurred vision, or visual changes of any kind.
ENT
Denies ear pain, hearing loss, ringing in ears, discharge. Reports no sinus problems, or nose bleeding. Complains of sore throat and aggravating pain when swallowing. Goes to dentist every 6 months per mom.
Gastrointestinal
Denies diarrhea, abdominal pain, or heartburn. He had his last bowel movement this morning and goes at least once a day.
Genitourinary
Denies urgency, frequency or burning and pain with urination. Reports no hematuria or change in color of urine. Denies penile pain.
Musculoskeletal
Denies back pain, joint swelling, stiffness, or muscle pain.
Heme/Lymph/Endo
Denies fatigue. Mother states swollen/tender cervical lymph nodes. Patient is appropriate size and weight for his age.
Neurological
Denies any syncope, seizures, transient paralysis, paresthesi.
3 month old baby Fathima Sampra presented with cough for 7 days. The cough was worse when lying down and caused waking at night. On examination, the baby had increased respiratory rate and bilateral crepitation at the lung bases. Differential diagnoses included bronchiolitis, bronchial asthma, and pneumonia. Treatment involved nebulized ipratropium and hypertonic saline, along with saline nasal drops. Oxygen supplementation was not needed as the baby's saturation was normal.
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2. Patient’s information
Name : K.K
Age : 11 years
Date of Birth : 11th September, 2012
Sex : Male
Date of admission : 21st April, 2024
Date of clerking : 23rd April, 2024
Ward : Children’s ward above 5 years
Religion : Christian
Residence : Mtendere
Source of history : Mother, patient and patient file
4. History of presenting complaint:
The patient was well until 2 weeks ago when he started having difficulties in breathing , it
was on and off but not severe.
2 days prior to hospital visitation the diffulties in breathing increased in intensity that he
failed to play and attend classes
• It was sudden onset
• Progressive
• Worse in the morning and sometimes evening
• Associated with intermitent wheezing ,chest tightness, dry cough ,chest pains
on lung sides bilaterrally intermittent ,non radiating , relieved by paracetamol.
• Fever that was intermittent ,worse in evening but no sweating , no weight loss
• No coughing blood, no palpitations, no difficulting breathing when lying
down or waking up in the night to catch air, no sweling of legs, trauma.
• Patient noted it always start by playing football, eating pork and sometimes
cold weather
• It is relieved by taking salbutamol
• It does affect his school attendance but not his grades
5. Complained to have diarrhea for 2 days prior to admission
• Sudden onset
• intermittent
• 4 times a day , could not quantify
• Waterly, mixed colour, but no blood
• Associated with vomiting, non projectile, 2 times a day, mixed with
food and generalised body weakness,worsened by eating and drinking
and relieved by sleeping.
• No blood
• Mild offensive
• No abdominal pain
• No yellowing of eyes
• No lack of appetite
• No distention or bloating
• No history of travelling recently or treament of malaria
6. Review of systems
General:
· Distressed and feels uncomfortable
Neurology:
· No headache, blurred vision , fainting,confusion, neck stiffness, dizness, numblenesss
Genitourinary:
· No pain passing urine , normal freguency, colour and quantity
Endocrine :
No heat intolerance and no hyperactive
7. Bones and joints:
· No joint pains
· No joints swelling
· No deformities
· No problem with walking
Skin:
· No rashes
8. Past medical History
Known asthmatic patient for 6 months diagnosed at chitundu hospital not on asmatic
treatment
This is first hospital admission
RVD- negative at Mtendere (verbally)
No diabetis, hypertension,tuberculosis,hypertension and sickle cell disease
Drugs allergies and surgeryhistory
Metromidazole 1 tab and amoxyllin no side effects noted
Allergic to spray, fumes, dust and pork
No surgical procedure or transfusion
Pregnancy and Birth history
Antenatal:
Planned pregnancy, attended antenatal clinic regular
No diabetis
No hypertension
No asthma
9. Perinatal:
Child was born at term, with birth weight of 3400 grams.
Born through a normal spontaneous vaginal delivery.
No complications during birth, the child cried soon after birth, did not convulse and
was not resuscitated and was able to breastfeed few minutes after birth.
Postnatal:
There was no maternal postnatal illness
Nutrition history
He was exclusively breastfed for the first 8 months of life. She was started taking
porridge at 6 months and nsima.
He has three meals per day; breakfast, lunch, and supper but without significant
snacks in between the main meals
10. Growth and developmental history
Attained all developmental milestones in time.
· Gross Motor
Able to play around and kick a ball and stand on one foot.
Started crawling at 9 months
Started walking at the end of year one
She started sitting at 8 months
· Fine Motor
Could could grasp moms finger by 5 months
Started scribbling on paper and house walls at 1 year and 7 months.
· Language and Hearing
Started articulating words as dada, mama at 8 months .
· Social behavior and play
Dress up by himself, smile and interact with the mother by the end of 2 years.
11. Immunisation history
All the immunisations given to him according to schedule.
Family history
There is no history of Astma , hypertension, diabetes and Tuberculosis and epilepsy in
both paternal and maternal sides
Siblings are all well
12. Social history
The child lives with the mother. They live in a one- bedroomed housewth iron sheets.
They get their water from tap and they cook using charcoal. No pets and poutry at
home but mother use sprays.
No people with diarrhoea diseases at home
Good sanitation around home
Summary
K.K ,11 years male known asthmatic patient for 6 months who presented with difficult
breathing and diarrhea for 2 days associated with wheezing, chest tightening
,cough,chest pains , fever, vomiting , allegic to dust ,pork, perfumes and fumes. No
heart palpitations, no orthpnea, paraxymal noctual dispnea, odema, jaundice, loss
weight and abdmonimal pain.
14. PHYSICAL EXAMINATION
General impression
Alert,distressed, weak, able to complete sentence and in good nutrition status , has a
cannula on the left hand, no clubbing, jaundice, cyanosis.
Vital signs
Day of admission Day of clerking
Axilla temperature: 380C
(fever)
Axilla temperature:
36.80C
Heart rate: 134 bpm Heart rate: 135 bpm
Blood Pressure: 120/85
mmHg
Blood Pressure: 119/75
mmHg
Respiratory rate: 22
cycles/min (tachypnoea)
Respiratory rate: 18cycles
/min
O2 saturation: 84 % in room
air (desaturating)
O2 Saturation: 96% on
room oxgen
15. Head, eye, ear, nose and throat
Head: No bruishes, normal hair growth
Eyes: no conjunctival pallor, no sunken eyes, .
Neck: no lymphadenopathy, no raised JVP
Mouth: no dry membranes, no sores, no oral thrush, no central cyanosis
16. Respiratory:
Inspection
· Respiratory distress,use of accessory muscles
· No scars
· No chest deformities.
Palpation
· No tracheal deviation
· Symmetrical chest expansion
Percussion
Resonant to percussion
Auscultation
Reduced air entry bilatelly
wheezes sounds in lower lobes bilaterally.
17. Cardiovascular:
Inspection
No scars indicating previous surgeries, no visible apex beat
Symmetrical chest expansion
Palpation:
Apex beat in 5th intercostal space mid clavicular line (no
displacement)
No heaves and no thrills
Regular pulse and good volume,
Auscultation
Normal heart sounds, no added sounds
18. Gastrointestine :
Abdomen
Inspection
· No scars, no previous surgical marks, the abdomen was flat,
distention, no tattoos and no hernias
Palpation
· No tenderness on light palpation
· No hepatomegaly or splenomegaly and no other palpable
masses on deep palpation
Percussion
· No shifting dullness , no fluid thrill
Auscultation
· Normal active bowel sounds
· No bruits
19. Central Nervous System:
Glasgow Coma score (Motor 6, Verbal 5 and Eye)
15/15
Cranial nerves
CN 1: I did not assess
CN 2: Pupils were reactive to light. Normal direct and
consensual reflex to light
CN 3, 4 & 6: Patient was able to follow with eyes. Normal eye
movements in all directions.
CN 5: Patient able to respond to touch at forehead, checks and
jaw with closed eyes
CN 7: able to raise eyebrows and strongly close eyes
CN 8: Able to respond to my instructions and was able to hear
with both ears
CN 9, 10 &12: No tongue fasciculation
Able to swallow
CN 11: Patient was able to shrug both shoulders
20. Upper and lower limbs (periphery) examination:
Right upper
limb
Left upper
limb
Right lower
limb
Right lower limb
Tone normal normal normal normal
power 5/5 5/5 5/5 5/5
reflexes normal normal normal normal
sensation normal normal normal normal
coordination intact Intact intact intact
21. Summary
K.K ,11 years male known asthmatic patient for 6 months who
presented with difficult breathing and vomiting for 2 days
associated with wheezing, chest tightening ,cough,chest pains ,
fever, vomiting , allegic to dust ,pork, perfumes and fumes. No
heart palpitations, no orthpnea, paraxymal noctual dispnea, odema,
jaundice, loss weight and abdmonimal pain.
On examination he was alert, distressed, weak, blood pressure
119/75, on oxygen therapy 4L via nasal prong ,tachypneic,
tachycardic , a fibrile, reduced air entry bilaterally with wheezes
and increased vocal fremitus bilaterrally.
