Recording Form Case Hoda
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أحمد العيادى 28-5-2005
5
*The mother brings her 10 months old girl Hoda to the outpatient clinic complaining of: Diarrhea & abdominal pain. *On examination: The child axillary’s temperature was 37 C. The child weight is 10 kg. This is here initial visit to the clinic.
أحمد العيادى 28-5-2005 37
10
months 10
Hoda Diarrhea & abdominal pain
5
The doctor checks the child for general danger signs he find the following: • • • •
The child is able to drink. The child does not vomit every thing. The child has no history of convulsions. The child is neither lethargic nor unconscious. • The child is not convulsing now.
أحمد العيادى 9-7-2004 37
10
months 10
Hoda Diarrhea & abdominal pain
The doctor asks the mother does the child have cough or difficult breathing: • She says, no.
أحمد العيادى 9-7-2004 37
10
months 10
Hoda Diarrhea & abdominal pain
The doctor asks the mother does the child have diarrhea: She says, yes. On assessment he finds the following: • Diarrhea since 5 days with blood in stools as the mother said. • The child is alert & interested in the surrounding. • The child has sunken eyes. • The child is thirsty. • The skin pinch goes back slowly.
أحمد العيادى 9-7-2004 37
months 10
10
Hoda
Diarrhea & abdominal pain
5
Some dehydration
dysentery
Then the doctor checks the child’s throat & he find the following: • There is no history of fever. • There is no history of sore throat. • There are no enlarged tender lymph nodes in the front of the neck. • There is red congested throat. • There is no exudate on the throat.
أحمد العيادى 9-7-2004 37
months 10
10
Hoda
Diarrhea & abdominal pain
5
Some dehydration
dysentery
Non streptococcal sore throat
The doctor asks the mother does the child have ear problem: She says, yes. On assessment he finds the following: • There is no history ear pain. • There is history ear discharge for 5 days. • There is no pus is seen coming out of the ear. • There is no tender swelling behind the ear.
أحمد العيادى 9-7-2004 37
months 10
10
Hoda
Diarrhea & abdominal pain
Some dehydration
5
dysentery
Non streptococcal sore throat
5
No ear infection
The doctor asks the mother does the child have fever: She says, no.
Then the doctor checks the child for malnutrition & anemia: • There is no visible severe wasting. • There is no oedema of both feet. • There is neither palmar nor mucous membrane pallor.
Not low weight No anemia
Abdominal pain
5
*The mother brings her 10 months old girl Hoda to the outpatient clinic complaining of: Diarrhea & abdominal pain. *On examination: The child axillary’s temperature was 37 C. The child weight is 10 kg. This is here initial visit to the clinic.
أحمد العيادى 28-5-2005 37
10
months 10
Hoda Diarrhea & abdominal pain
5
The doctor checks the child for general danger signs he find the following: • • • •
The child is able to drink. The child does not vomit every thing. The child has no history of convulsions. The child is neither lethargic nor unconscious. • The child is not convulsing now.
أحمد العيادى 9-7-2004 37
10
months 10
Hoda Diarrhea & abdominal pain
The doctor asks the mother does the child have cough or difficult breathing: • She says, no.
أحمد العيادى 9-7-2004 37
10
months 10
Hoda Diarrhea & abdominal pain
The doctor asks the mother does the child have diarrhea: She says, yes. On assessment he finds the following: • Diarrhea since 5 days with blood in stools as the mother said. • The child is alert & interested in the surrounding. • The child has sunken eyes. • The child is thirsty. • The skin pinch goes back slowly.
أحمد العيادى 9-7-2004 37
months 10
10
Hoda
Diarrhea & abdominal pain
5
Some dehydration
dysentery
Then the doctor checks the child’s throat & he find the following: • There is no history of fever. • There is no history of sore throat. • There are no enlarged tender lymph nodes in the front of the neck. • There is red congested throat. • There is no exudate on the throat.
أحمد العيادى 9-7-2004 37
months 10
10
Hoda
Diarrhea & abdominal pain
5
Some dehydration
dysentery
Non streptococcal sore throat
The doctor asks the mother does the child have ear problem: She says, yes. On assessment he finds the following: • There is no history ear pain. • There is history ear discharge for 5 days. • There is no pus is seen coming out of the ear. • There is no tender swelling behind the ear.
أحمد العيادى 9-7-2004 37
months 10
10
Hoda
Diarrhea & abdominal pain
Some dehydration
5
dysentery
Non streptococcal sore throat
5
No ear infection
The doctor asks the mother does the child have fever: She says, no.
Then the doctor checks the child for malnutrition & anemia: • There is no visible severe wasting. • There is no oedema of both feet. • There is neither palmar nor mucous membrane pallor.
Not low weight No anemia
Abdominal pain
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