2. Personal data
o Name: Isma’il Mostaf Nor
o Age: 9 months
o Sex: Male
o Residence: Janaale
o Weight: 6.8 kg
o Height: 70
o Z-score: -2
o Date of Admission: 09/01/2024
o Date of History: 11/01/2024
o Date of Birth: 08/05/2023
o Place of Birth : Janaale
o Informer: Mother
o Hospital: Marka Hospital
o Card serial number: 614
o Ward: Ped (SC)
o Bed number: 03
o Contact mobile: 619455263
4. History of present illness
The patient came to the pediatric (SC) room with a complaint of
diarrhea and vomiting that persisting for the past twelve days that
characterized by offensive white color. These symptoms are
accompanied by intermittent fever. The patient reports the fever is both
during day and night and Relief with administration of parastomal
syrup the mother said she replaced the milk that takes the baby and
eventually get diarrhea followed by vomiting.
5. Past Medical history
• Hospitalization: No hospitalization before
• Immunization: BCG, bent 1, polio 1, no other vaccines.
• Chronic Diseases: No Chronic Diseases
• Medications: yes previous medications
• Clinical physicians center or health canters: she visit MCH Janaale 3 times.
• Blood transfusion: No history of blood transfusion.
• Surgery history: No history of surgery.
• Previous imaging: No Previous imaging
• Drug allergy: Unknow of drug allergy.
6. • Past: parastomal syrup, artemether syrup,
mebendazole Syrup
• Presents: current drug will be discussed
on management section.
•Drug allergy: unknow of drug allergy
Drug history includes
7. • Past: No remember
• Presents: yes, we will be discus the investigation.
• Interpretation: Incomplete.
Lab History include
8. Birth history
AnAntenatal historyhist
• Health status of mother: The health status and also nutritional status
of the Mother was good as the mother said.
• Anti-natal care of the mother during pregnancy:
A. supplemental iron and folic acid and vitamins: take supplemental
iron and folic acid, parastomal tab and TT
B. Blood transfusion of the mother: No history of Blood transfusion.
C. Vaccination of the mother: yes
D. Radiological of the mother: No Radiological of the mother.
9. Cont……….
A. Medications of the mother during pregnancy: Take supplement iron and
folic acid and parastomal.
B. Monitoring of blood sugar, blood pressure, and hemoglobin control is
conducted by Pharmacy Janaale
C. Medical illness before & during pregnancy: back pain
• Obstetric complications in past pregnancy: yes infection
• Trauma of the mother during pregnancy: No trauma
• Travels of the mother during pregnancy: No Travels of the mother
• Surgery of the mother during pregnancy: No history Surgery
10. Birth history
Natal or neonatal history: at birth
• Duration of labour: 39 weeks.
• Duration of Labour: 6 hours.
• Place of delivery: Home
• Presentation: cephalic presentation.
• No complication during delivery
• Interpretation: no Good natal history
11. Past Natal history: at birth
The baby cried immediately after birth, displaying a pink color. No
birth injuries were observed, and there was the passage of
meconium and urine within the first 24hour. The mother does not
recall the birth weight.
12. Feeding history
Breast feeding:
•Breast feeding begins: 2hr after birth
•Frequency of Breast feeding: every time the baby caries.
•Duration of feeding on each Breast: until the baby feels satiety.
Breastfeeding: was discontinued at 4 months due to vomiting and diarrhea caused by pregnancy.
•Formula feeding: started at 4 Months of age.
• Type of formula milk: Hilwa milk Potel feeding
Interpretation Breast feeding : not good
• Immunization or vaccination history: BCG, bent 1, polio 1, no other vaccines.
• Interpretation: In complete
13. Growth and Developmental history
The baby starts neck at 4months
at 5 month sits with support
At 6 month sits alone
Crawling at 6 months
At 9month begins to crawl
Interpretation: Good
14. Family history
Both parents are alive and health.
The age of mother is 20yrs and age of father is 25yrs.
No, there is consanguinity
There Is no known chronic disease.
15. Social-economic history include
• Habit: mother no bad habit but father he is smoker and eating Chad.
• Leaving condition: they live cottage
• Job: father: job farther Soldier and mother housewife education of
mother secondary school.
• Economic income: middle socio-economic level.
• Household: 2boy 1gril father and mother.
• Water source: a river water
• Interpretation: Middle socio-economic level.
18. General appearance
• Head: normal shape and size
• hair distribution are normal
• Eyes: No signs of conjunctivitis. The area under the eyes
appears to be of a white color.
• Ear: normal hearing, no discharge.
• Nose: no nasal discharge.
• Mouth: no oral thrush, no Ulcer.
• Neck: no neck stiffness, no jugular vein distention.
19. Cont…..
• Chest: normal shape
• Lungs: clear
• Heart: normal s1 s2 sound
• Abdomen: soft no scars
• Prenium and genitalia: both test are descended no circumcised
• Rectum: normal
• Back or spine: no trauma no scar
• Muscular system: no Muscular system
• Nervous system: no sensory loss
• Motor system: normal
• Cranial nerves: no cranial nerve palsy
20. Reflex
• Grasp reflex: normal
• Motor reflex: normal
• Rooting reflex: normal
• Sucking reflex: normal
• Asymmetric tonic neck reflex: no
21. Summary
On May 08, 2024, The patient came to the pediatric (SC) room with a
complaint of diarrhea and vomiting that persisting for the past twelve days
that characterized by offensive white color. These symptoms are accompanied
by intermittent fever. The patient reports the fever is both during day and
night and Relief with administration of parastomal syrup the mother said she
replaced the milk that takes the baby and eventually get diarrhea and
vomiting.
•V/S BP: T: 37c Pulse: 132 RR: 30 Spo2: 98%
