ID:

Name: Firas yaser Younes

Age: 4 month- old
Address: Khalil
Date of admission: 2/12/2013
Date of History taking: 2/12/2013

Informant:
Mother who seems to be not reliable due to low IQ .

Chief Complain:
Abnormal movement for 6 hour duration prior to admission .

History of present illness:

Firas Younis who was in his usual state of health until 2 days before when his
mother felt that her child was feverish ( not documented , without chills ) and
hypoactive , then she gave him supprisotary anti pyretic with no improvement .
Then , few hours later the patient complained of vomiting ( with each feed , milky ,
and projectile ) and refuse feeding , and diarrhea ( 4 dippers , fully submersed ,
greenish in color with mucus and bad smell ) .
In the 2nd day at 4 am , the patient experienced abnormal movement of the hand ,
up rolling of the eye , cyanosis in the lips , decrease level of concisness and persist
till he arrived to the hospital . so , she went to a near hospital and advised her to go
to Rafedia hospital by ampulance .

These symotoms were associated with pallor , hypoactivity , sever dry lips , sleep
disturbance and abd.pain .

There was, no cough ,no runny nose or ear discharge , no wheezes , no

conjunctivitis , no rash , no change in urine color , no photophobia ?? .
At 2/12/2013 Firas younis came to Rafedia hospital and admitted through ER to
ICU.

Systemic Reviews:
1) General,no skin changes , no brusis,no sweating , suspect weight change 3
kg before one month .
Eyes: no redness
2) CVS: no edema , no palpitation.
3) Respiratory system:
4) GI:
5) Neuromuscular: irritable, no joints swellings

Past History:
1. Antenatal: Good health of mother during pregnancy, she visited pregnancy
clinics regularly, U/S done and was normal, no complications during
pregnancy
2. Neonatal: he is a product of, CS due to fail of induction , GA 9 months, 2
kg
3. Postnatal: baby pink color, no cyanosis, no jaundice, no NICU admission
4. Growth and development:
He can upraised head at 2 months
Cooing at 3 months .
Social smile 3 month .
He can follow moving object .
5. Nutrition:

 Exclusively bottle feeding from the 1st day of life .. cause no milk
production . 3 standard measurement each for 30 to 60 min ,,similac
6. Past medical hx: URTI , no previous hospitalizations\.
7. Past surgery : free.
8. Drug history:anti pyretics .
9. Allergy : no known allergons
10.Immunization :up to date, last one before one month , no complications .
11.No blood transfusion .

Family History:
free.

Social History:
non consanguineous
he is the 1st son .

He lives in 1st floor, well ventilated house.

low economic status .
sheep herder
no smoking
No domestic animals

Physical Examination:
1. General appearance: patient looks ill, lying in the bed , lethargic, pallor ,dry
mucous membrane , un responsive ,sunken eye , depressed ant .fontanel ,
decrease skin turgor , prlong capillary refill >4sec , weak pulse, cold
extremity , ,no cyanosis, no jaundice, , canula inserted into his right hand

2. Vital signs:
Temp: 38.5 C
HR: 205/min
RR: 43/min
BP: 65 over 40
3. Growth parameters:
Weight: 3 kg
Length: 53 cm
below 5th percentile
Head circumference : 42 cm
4. Eyes: pallor, no jaundice , no conjuctivitis
5. ENT: ears were not examined by otoscope but by inspection there was no
discharge, no redness, and no tenderness.
6. Respiratory system:
Inspection: no subcostal retraction, no visible pulsation, no scars, no
tracheal tug, no nasal flaring
Palpation: trachea is centralized
Percussion: ---- Auscultation:, harsh breathing .
7. CVS:
Inspection: no chest deformities, no visible pulsation, no scars
Palpation: no thrills, no heaves, PMI (5th intercostal space MCL)
Auscultation:tachycardia, no murmers, no added sounds , no radio
femoral delay .
8. GI system:
Inspection: abdomen flat , umbilicus centrally located, normally
inverted, no fullness and echomosis on flanks, no pigmentations, no
scars, no visible masses, no dilated veins, no jaundice
Palpation: superficial palpation revealed no masses. Deep palpation
not palpable liver and spleen , no masses
Auscultation: normal bowel sound
9. Neurological examination :
semi conscious and unresponsive
Crainial nerve ; normal , no abnormality detected . symmetric face
Normal tone , reflexes : sucking ,rooting, blinking , grasp , step

Summary:
Firas Younis a 4 month old patient came to hospital complaining from
convulsion and sever dehdration ,on examination BP 65 HR 180 , dry mucous
membrane . weak pulse and prolonged capillary refill .

D.D:
sepsis
Acute gastroenteritis
Meningitis