PATIENT CASE SHEET

MRN : 391581 DOB : 05/02/2004

Name : HAYA DABBAGH Age : 17 Y 0 M 15 D

Company : ADNIC - Abu Dhabi National Insurance Co Gender : Female

Visit No. : VST2087781 Visit Type : OUT

Visit Date : 20/02/2021 15:31:51 Department : Paediatrics

Doctor : GHIATH SANDOUK

Chief Complaints :
Chief Complaint Onset Date. Interval Interval Type Severity Pain Entered By Date Comment
Score
decreased appetite 06/02/2021 2 Week 0 GD90074 20/02/2021 16:01:25
Cough 15/02/2021 5 Days 0 GD90074 20/02/2021 15:56:04

HPI Elements

Cough Location CHEST

Cough Quality PRODUCTIVE
Cough Associated symptoms no fever
Cough Timing Constant
decreased appetite Timing ON AND OFF
decreased appetite Associated symptoms NOT GAINING WEIGHT
decreased appetite Location abdomen

Pain Scale

Vitals

ROS
ROS Category ROS Description Comment
Constitutional No weight loss, fever, chills, weakness or
fatigue
Ear, Nose, Mouth, and Throat No hearing loss, sneezing, congestion,
runny nose or sore th
Cardiovascular No palpitations or edema
Respiratory Abnormal COUGH
Gastrointestinal Abnormal DECREASED APPETITE

Chronic Remarks
Chronic Disease List :
nil

Social History
Marital Status : Single
Educated Yes
Willing to learn Yes
Family History
Complication Relation
No problems Father Mother

Surgery History
NIL
Surgery History Comments
NIL
Medication History
NIL

Medication History Comments

NIL
Allergies/ Reactions
NIL

Allergy Comments
NIL

Physical Examination

Examinations Comment Provider Date & Time Created By

Constitutional/Vital Normal NORMAL NO FEVER, NO WEIGHT GHIATH SANDOUK 20/02/2021 15:51:51 GHIATH
Signs LOSS SANDOUK

Eyes EYES: PERRL, GHIATH SANDOUK 20/02/2021 15:51:53 GHIATH

EOMI. Fundi SANDOUK
normal, vision is
grossly intact.
Ear, Nose, Mouth, EARS AND GHIATH SANDOUK 20/02/2021 15:51:55 GHIATH
and Throat NOSE CLEAR, SANDOUK
THROAT
NORMAL
Cardiovascular normal heart GHIATH SANDOUK 20/02/2021 15:51:57 GHIATH
sound and rhythm, SANDOUK
no murmur
Respiratory Abnormal rales on both GHIATH SANDOUK 20/02/2021 15:56:28 GHIATH
sides SANDOUK

Gastrointestinal Comments ANOREXIA GHIATH SANDOUK 20/02/2021 16:01:58 GHIATH

SANDOUK

Musculoskeletal Normal No Abnormality GHIATH SANDOUK 20/02/2021 15:52:03 GHIATH

detected SANDOUK

Integumentary normal skin GHIATH SANDOUK 20/02/2021 15:52:05 GHIATH

SANDOUK

Treatment Plan Details

Treatment Plan Comments

EHR Diagnosis

Diagnosis Date & Time Diagnosis Code Diagnosis Name Is Principal Recorded By

20/02/2021 15:56:32 J45.991 Cough variant asthma Primary GHIATH

SANDOUK
 20/02/2021 16:02:01 R63.0 Anorexia Secondary GHIATH
SANDOUK
20/02/2021 16:08:13 J30.9 Allergic rhinitis, unspecified Secondary GHIATH
SANDOUK
Narrative Diagosis : COUGH VARIANT ASTHMA
ANOREXIA
ALLERGIC RHINITIS
EM Diagnosis

Diagnosis Date & Time Diagnosis Code Diagnosis Name Is Principal Recorded By

20/02/2021 16:08:05 J45.991 Cough variant asthma Primary GHIATH SANDOUK

20/02/2021 16:08:05 R63.0 Anorexia Secondary GHIATH SANDOUK

Reason Of Visit:
ROV Code Desc
R63.0 Anorexia
R05 Cough

Medications :
Ord. Date & Drug Name Dosage Route Frequency No.of MOH Start & End Date Remarks
Time days
PRE000000935984
20/02/2021 TELFAST 180MG TAB 1 TAB Oral Once daily 30 L91-5130- 20/02/2021-21/03/2021
16:06:27 30S 02328-02
20/02/2021 DYNAMOGEN ORAL 1 AMP Injection Twice daily 60 E77-1550- 20/02/2021-20/04/2021 30 MINUTES
16:06:27 SOLUTION 00438-01 BEFORE
EATING
20/02/2021 FLUTIFORM 1 Twice daily 30 J07-1995- 20/02/2021-21/03/2021
16:06:27 125MCG/5MCG INHALATIO 02430-01
INHALER NS
20/02/2021 PULMICORT 0.5mg/ml 1 Nebule Twice daily 10 B46-4387- 20/02/2021-01/03/2021
16:06:27 -2ml Neb Soln 20s NEBULES for 00779-01
Inhalatio
n
20/02/2021 VENTOLIN NEBULES 1 Nebule Three times a day 10 F60-5477- 20/02/2021-01/03/2021
16:06:27 2.5 MG/2.5 ML 40S NEBULES for 05004-01
Inhalatio
n
Plan Of Care :
ADVISED TO CARRY ON WITH MEDICINE AT HOME

AVOID EXPOSURE TO CIGARETTE SMOKE AND OTHER FORMS OF SMOKE, STRONG ODORS AND PERFUMES, AIR
POLLUTION

AVOID ALLERGENS SUCH AS DUST MITES, POLLENS, ANIMAL DANDER AND MOLDS.

ADVISED TO GIVE VITAMIN D REGULARLY

ALERT AND COOPERATIVE

AMBULATORY

ACCOMPANIED BY MOTHER
Treatment Plan
ADVISED TO CARRY ON WITH MEDICINE AT HOME

AVOID EXPOSURE TO CIGARETTE SMOKE AND OTHER FORMS OF SMOKE, STRONG ODORS AND PERFUMES, AIR
POLLUTION

AVOID ALLERGENS SUCH AS DUST MITES, POLLENS, ANIMAL DANDER AND MOLDS.

ADVISED TO GIVE VITAMIN D REGULARLY

ALERT AND COOPERATIVE

AMBULATORY

ACCOMPANIED BY MOTHER
 Summary of all Radiology

Procedure Notes

Recorded By: GHIATH SANDOUK

Name Of Doctor: GHIATH SANDOUK

Department: Paediatrics
License Number: D2905

Date : 19/09/2021 Page 4 of 4