This document contains a case study and assessment of a 4-year-old preschooler named Ms. Prarthana. On observation, she was semi-conscious and occasionally responded to verbal commands. Her vital signs and anthropometric measurements were recorded. On examination, she had a squint in both eyes and neck rigidity. Her developmental history and immunization history were noted. She comes from a lower-middle class family with consanguineous parents.
Case presentation on mengoencephalitis |Inflammation of the brain NEHA MALIK
Inflammation of the brain and surrounding tissues, usually caused by infection.
Meningoencephalitis is a condition that's usually caused by a virus, bacterium, parasite or other microorganism. Examples include West Nile virus, mumps or tuberculosis.
Symptoms vary, depending on the cause. They may include fever, confusion, vomiting, seizures or, if left untreated, death.
Treatment may include antibiotics, antivirals or supportive care, depending on the origin of the disease.
Documentation Electronic Health Record· DocumentationVitalsDustiBuckner14
Documentation / Electronic Health Record
· Documentation
Vitals
Student Documentation
Model Documentation
Vitals
Ms. Tina Jones vital signs are as follows: Temperature=37.2C (98.9F), HR=78, RR=15, B/P=128/83, Sa02=99%, Wt:90kg (198lbs), Ht: 5'7", Spirometry= FVC 1.78L, FEV1=1.549L.
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Health History
Student Documentation
Model Documentation
Identifying Data & Reliability
Ms. Joes is 28 years old African-American female who visited the clinic for pre-employment physical. She is responsible for self, and able to give history information of self freely without hesitation. she is religious, single, educated, likes to go out with her friends. Her occupation is Smith, Stevens, Stewart, Silver & Company.
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General Survey
Ms. Jones alert and oriented x4, to person, place, time and situation. she is aware of her diagnosis. She is well groomed and dressed appropriately, looked well nourished, well developed and has very good hygiene. She answered questions appropriately without hesitation. she seated well upright in the examination table.
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Reason for Visit
Ms. Jones visit is for pre-employment physical.
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History of Present Illness
Ms. Jones stated that she has recently got a job at new place and she is supposed to provide a physical examination. Ms. Jones did not voice any acute concerns. The gynecologist diagnosed her with polycystic ovary syndrome (PCOS). She was prescribed oral contraceptives that helped improve her acne. She has history of diabetes and asthma. And she stated that she has modified her lifestyle habit.
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Medications
Metformin 850 mg PO BID, Flovent 110 mcg/spray, albuterol 90 mcg/spray MDI 1 to 3 puffs every 4 hours as needed. Tylenol 500 to 1000 mg PO PRN for headaches, ibuprofen 600 mg PO TID PRN for menstrual cramps.
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Allergies
Ms. Jones is allergic to penicillin (PNC), cats, dust. Denies food and latex allergies.
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Medical History
Ms. Jones was diagnosed with asthmas when she was 2 and half years old, and the she had asthma attack 3 months ago. She was diagnosed with diabetes when she was 24 years of age. she was diagnosed with PCOS 4 months ago, and
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Health Maintenance
She had pap smears 4 months ago, had eye examination 3 months ago, had dental checkup 5 months ago. Abide by the car seat belt by putting seat on while driving. She uses sun screen to prevent sun burnt, PPD was done 2 years ago and it was negative.
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Family History
Ms. Jones stated that her maternal grand-mother died of stroke, history of hypertension and high cholesterol, at age 75. Maternal grand-father died of stroke, hypertension and high cholesterol at age of 78. Paternal grand-father died of colon cancer at age 65, also had type 2 diabetes. Paternal uncle died suddenly of cancer, kidney disease, sickle cell anemia and thyroid problems. Paternal grand-mother is 82 years old and still living, and she has hypertension.
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Social History
Ms. Jones is currently living with her mother and her sister, but had lived independently since she was ...
Case presentation on mengoencephalitis |Inflammation of the brain NEHA MALIK
Inflammation of the brain and surrounding tissues, usually caused by infection.
Meningoencephalitis is a condition that's usually caused by a virus, bacterium, parasite or other microorganism. Examples include West Nile virus, mumps or tuberculosis.
Symptoms vary, depending on the cause. They may include fever, confusion, vomiting, seizures or, if left untreated, death.
Treatment may include antibiotics, antivirals or supportive care, depending on the origin of the disease.
Documentation Electronic Health Record· DocumentationVitalsDustiBuckner14
Documentation / Electronic Health Record
· Documentation
Vitals
Student Documentation
Model Documentation
Vitals
Ms. Tina Jones vital signs are as follows: Temperature=37.2C (98.9F), HR=78, RR=15, B/P=128/83, Sa02=99%, Wt:90kg (198lbs), Ht: 5'7", Spirometry= FVC 1.78L, FEV1=1.549L.
N/A
Health History
Student Documentation
Model Documentation
Identifying Data & Reliability
Ms. Joes is 28 years old African-American female who visited the clinic for pre-employment physical. She is responsible for self, and able to give history information of self freely without hesitation. she is religious, single, educated, likes to go out with her friends. Her occupation is Smith, Stevens, Stewart, Silver & Company.
N/A
General Survey
Ms. Jones alert and oriented x4, to person, place, time and situation. she is aware of her diagnosis. She is well groomed and dressed appropriately, looked well nourished, well developed and has very good hygiene. She answered questions appropriately without hesitation. she seated well upright in the examination table.
N/A
Reason for Visit
Ms. Jones visit is for pre-employment physical.
N/A
History of Present Illness
Ms. Jones stated that she has recently got a job at new place and she is supposed to provide a physical examination. Ms. Jones did not voice any acute concerns. The gynecologist diagnosed her with polycystic ovary syndrome (PCOS). She was prescribed oral contraceptives that helped improve her acne. She has history of diabetes and asthma. And she stated that she has modified her lifestyle habit.
N/A
Medications
Metformin 850 mg PO BID, Flovent 110 mcg/spray, albuterol 90 mcg/spray MDI 1 to 3 puffs every 4 hours as needed. Tylenol 500 to 1000 mg PO PRN for headaches, ibuprofen 600 mg PO TID PRN for menstrual cramps.
N/A
Allergies
Ms. Jones is allergic to penicillin (PNC), cats, dust. Denies food and latex allergies.
N/A
Medical History
Ms. Jones was diagnosed with asthmas when she was 2 and half years old, and the she had asthma attack 3 months ago. She was diagnosed with diabetes when she was 24 years of age. she was diagnosed with PCOS 4 months ago, and
N/A
Health Maintenance
She had pap smears 4 months ago, had eye examination 3 months ago, had dental checkup 5 months ago. Abide by the car seat belt by putting seat on while driving. She uses sun screen to prevent sun burnt, PPD was done 2 years ago and it was negative.
N/A
Family History
Ms. Jones stated that her maternal grand-mother died of stroke, history of hypertension and high cholesterol, at age 75. Maternal grand-father died of stroke, hypertension and high cholesterol at age of 78. Paternal grand-father died of colon cancer at age 65, also had type 2 diabetes. Paternal uncle died suddenly of cancer, kidney disease, sickle cell anemia and thyroid problems. Paternal grand-mother is 82 years old and still living, and she has hypertension.
N/A
Social History
Ms. Jones is currently living with her mother and her sister, but had lived independently since she was ...
QA Paediatric dentistry department, Hospital Melaka 2020Azreen Aj
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How many patients does case series should have In comparison to case reports.pdfpubrica101
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2. To assess the growth and development of the
child in relation to her age and to recognize
any deviation from the normal
AIM
3. Ms Prarthana
4year old , pre- schooler
On Observation:-
Semi-conscious,
Occasionally responds to verbal commands
4. VITAL SIGNS
.Temp - 99. F
. Heart rate - 110/mt
. Respiratory rate - 32/mt
. BP - 110/66 mm of Hg
5. ANTHROPOMETRY
. Height - 98cm
. Weight on admission - 11.5 Kg
. Head circumference - 48cm
. Mid arm circumference - 110/66 mm of Hg
6. HEAD
. The head appears normal in size and
symmetry
. Hair is black ,there is no signs of
nutritional deficiency
. No dandruff present , no swelling
7. EYES
. Squint is present, both eyeballs inwadely
deviated. There is no signs jaundice,
conjunctivitis etc.
. Both pupils are reacting to light .
8. EARS
. Appears normal in size ands shape.
. No signs of any infection in the ear noticed.
9. MOUTH
. All Primary teeth are present.
. No evidence of any dental caries
. Mild oral thrush is present.
. Tongue looks moist
. Lips are normal
10. NECK
. Neck rigidity is present
. Tracheostomy tube in sites
. Tracheostomy was done on 17/08/11
. Suture area is clean an healthy
11. CHEST
. Chest looks normal in size,shape summetry
and movement
. At present movement of the chest wall is
symmetric bilaterally and co-ordinated with
breathing
12. ABDOMEN
. Abdomen appears flat
. There is no signs of any polydactyl and
syndactyly and clubbing
. No sign of any dehydration present
Umbilicus is normal in size , no evidence of
any abnormalities or hernias noticed
13. HAND & FEET
. Extrimities appears cold;and pale
. There is no signs of any polydactyly and
syndactyly and clubbing
. All four limbs movement are restricted.
. The grasp reflex is very weak
. Resistence to passive movement
. No pedal edema
14. AUSCULTATION
. Chest : air entry to both the lungs are
normal.
. Abdomen : Peristalsis heard ; no signs of
any abnormal peristalsis
15. PALPATION
. There is no evidence of any
submental,cervical,tonsillar or inguinal
lymphadenopathy
. Liver is palpable ,spleen is not palpable
17. PRENATAL & BIRTH HISTORY
. Mother was booked case,immunized
against Tetanus
. Her first , second and third trimester were
uneventful.
. Delivery vaginaly at term.
. Birth weight was 2.9 kg
. Baby cried immediately after birth
. Breast feeding started immediately after
birth
. Infancy period was uneventful
18. DEVELOPMENTAL HISTORY
As per mothers:-
. Neck holding - 4 months
. Social smile - 3 months
. Recognition of mother - 3 months
. Sitting with support - 7 months
. Sitting without support - 8 months
. Stand with support - 10 months
. Walks without support - 1 year
. Running - 15 months
MS. PRASTHANA was attending nursery school
since last 1 year. She was able to recite nursery
poems
19. SOCIAL HISTORY OF FAMILY
Belongs to lower- middle class family.
Parents had a consangenous marriage ( Married to uncle’s
daughter)
Mr.Pandurang
(Father 27 years
Mrs. Sunder
(Mother 24 years)
Prarthana
(4 years)
Samar
(2 years)
20. IMMUNIZATION HISTORY
. Immunized till age.
. BCG OPV ,DPT , MEASLE are taken in
time
. Polio vaccine were also given during pulse
polio programme
