You are on page 1of 3

Medical History Sheet

Prepared by: Mohammed Younis Shaheen Supervisor : Dr. Mahmoud Alsalhi

Personal Hx: Osamah Mohammed Alqouqa, 6 month old infant, male, from Gaza city, he is insured. Presented to Alnasser Pediatric Hospital ER on Monday, 14/1/2013 , 5.50 p.m. carried by his father. This history was obtained from his father. Present Complaint The patient was presented with petechial rashes all over the body for 10 hrs duration prior admission. Hx of present illness The above mentioned patient was doing well till the morning prior admission when he started developing a sudden onset petechial rashes that started symmetrically in the both feet and extended all over the body later. There was no associated fever or chills , no itching, no hx of bleeding from nose or tongue, no hx of hematemsis, vomiting, cough or hymoptysis, no hx of hematuria, no weight loss. Before admission to our hospital parents sought medical help at the nearest UNRWA clinic and they made full blood count and discovered low platles counted 10.000 and they refered the patient for evaluation at Alnasser Pediatric hospital. Father stated that his son experienced an upper respiratory tract infection 2 weeks before that was treated by paracetamole syrup only. Past medical Hx No history of similar complaints , No history of Medical admissions, No history of Surgical admissions, No history of blood transfusion. Perinatal Hx Normal vaginal delivery, no pregnancy complications, no history of maternal illness during pregnancy, no neonatal complications, no neonatal ICU admission. Breast feeding Hx Exclusive breast feeding was continued till the age of 4 months, then mother introduced other fluids and formula milk besides.

He wasn't in respiratory distress with an abdomino-thoracic reppiration. CVS Ex & Chest Ex By inspection the chest was moving symmetrically bilatraly during respiration. . Completing abdominal examination there was no inguinal lymph node enlargement. there was no tender area. no pallor. was measured 8 kg and length was measured 64 cm. no delay Family Hx & Social and environmental Hx No family Hx of similar conditions No family Hx of bleeding disorders or other blood diseases Good ventilated home. The liver span was measured 7 cm. organomegaly or abnormal pulsations. no jaundice. The apex beat was diffused poorly localized behind the 5 th rib. no scars . The patient wt. he was sleepy with a GCS of 13/15. petechial non blanching rashes were distributed heavily all over the body including tongue and lips. Abdominal Ex By inspection the abdomen was within average size and shape. no other swellings or hernias. no hydrocele. the was no shape abnormality. no back abnormalities other than the rash. The infant was circumcised. good economic status Vital Signs HR: 120 bpm BP:85/55 Temp:37. no complications Developmental Hx: up to age. the apex beat was not seen. there was no visible masses or pulsations or dilated veins. no cyanosis. there was an extensive non-blanching petichial rashes all over the abdomen and extending to back. There was no dysmorphic features. The umbilicus was centrally located. By palpation the trachea was centrally located. By palpation there was no tenderness. no dilated veins or abnormal pulsations. no palpable masses. he was looking ill.5 RR:32 General Ex The patient was lying supine on his back on his bed.Vaccination Hx: Full up to age. inverted and clean.

Quinidine. liver enzymes Plan of Management 1. good tendon reflexes. the tone and power of the upper limbs were where within normal limits. no added heart sound. HIV. aPTT. Follow up clinical status and platlets. Platlet transfusion indicated in case of intracranial hemorrhage 6. vocal resonans was equally heared bilateral anteriorly and posteriorly.Auscultating chest there was good air entry bilaterally and there was harsh vesicular breathing. Sulfonamide) Autoimmune Disorders(SLE) Leukemia (ALL) Acquired marrow failure syndrome (aplastic anemia) Inherited thrombocytopenic disorders(thrombocytopenia-absent radius syndrome. Neurological / muscular Ex The patient was sleepy with GCS of 13/15. Hepatitis. ESR. Monitor vitals 3. Muscels was within normal bulk and no muscle wasting. Provisional Dx: Idiopathic/immune thrombocytopenic purpura DDx Viral infection(IMN. Auscultating heart. CRP. blood film. there was normal heart sound. nothing else abnormal. there was no dysmorphic features. BT. LDH. discharge when platelets > 30000 and stable vitals. By percussion no abnormality was detected. uric acid. Wiskott-Aldrich syndrome) LAB INVx Latest CBC (on admission) : platlets 3000 .1) Drug exposure(Heparin. the pupil was round regular and responsive. no joint limitation of movement. Also the following were ordered : PT. . Iv Ig 1g/kg one dose 4. no swellings or tenderness. the position was normal supine position . no murmers. Restrict activities to avoid trauma and bleeding 2. the tone and power of the lower limbs were where within normal limits. Steroids and Anti-D show good effect. 5.