Source of History:

The patient
Reliable, Co-operative, Informative

Patient’s ID:
20-year-old woman, First child of three
children, From Tehran, Living in Tehran

Chief Complaint:
Sputum Culture Positive for
Pseudomonas
 Presenting Illness:
Patient is a 20y/o woman with Cystic
Fibrosis who had cough and steatorrhea
when she was 3 years old. The patient was
treated with antibiotics for several years
with misdiagnosis of common cold until
finally at 9 years old she was diagnosed
with CF after genetic testing, sweat chloride
test and positive fat drop test in stool. She
has been hospitalized for approximately 15
times since her diagnosis and has been
treated with long term Ciprofloxacin.
The patient has had exacerbated
productive coughs with light green
coloured sputum for 2 months. Coughs are
more severe in mornings and improve with
usage of Salbutamol spray. She has trouble
breathing after continuous coughs.
 Presenting Illness:
Patient gives no history of current or
recent fever but reports having chills.
She has had 2 episodes of headache
located in frontal and occipital parts of
her head in the past month. Headache is
positional and is worsen by bending over.
It also deteriorates at nights.
No history of current or recent diarrhea
or vomiting although patient gets
nauseous after continuously coughing.
The last sputum culture obtained from
the patient in 31st of Khordad is positive
for Pseudomonas.
 Past Medical History

Neonatal:
First child of G5P5L3Ab0D2 mother, she
was delivered via C/S due to repeat. The
pregnancy and delivery was
uncomplicated. Born as a term infant with
birth weight of 2800 gr without Hx of
admission in NICU.
 Past Medical History

Past Hospitalizations:
After CF diagnosis at 9 years old, Pt has
been hospitalized for 15 times.
(approximately)

Immunizations:
Vaccination was fully completed according
to national protocol of vaccination.

Past Surgical History:

Arteriovenous access (port) in 17 which
got removed at 18
 Allergy History

Allergy History
Hx of dyspnea following usage of
Vancomycin and Ceftazidime + Skin
rashes following eating pepper
 Growth and Development

Growth:
Weight: 43 kg Height: 161 cm BMI:16.3

Development:
Normal growth and development

:
 Drug History

Tab Ciprofloxacin 500 mg TDS

Tab Cefixime 200 mg BD
Spray Atrovent 1 puff BD
Spray Salbutamol 2 puff QID
Pearl Vit E 400 Daily
Cap Zinc Daily
Pearl Vit A 25000, 3 times per week
Pearl Vit D 50000, once weekly
Tab Vit K 40 mg, 2 times per week
 Family History

Parents are close relatives (First Cousins)

The first child of the family has died at 18
months due to meningitis.
The second child of the family has died at 6
months due to bowel obstruction.
Patient is the third child; the last two
children are healthy.
General Appearance: Physical Examination
Patient is a young woman, awake,
alert and oriented who answers
questions and co-operates. She is not
ill or toxic. She is not in distress.

Vital Sign:
T: 36.6
PR:90
RR:18
BP:115/75

Skin:
Skin is not pale or icteric. No
petechiae or purpura was seen. No
rashes or pathological skin legions
was observed.
No rashes.
 HEENT Physical Examination
Head & Neck:
Neck: No tracheal deviation. No decrease in
ROM. No lymphadenopathy, goiter or masses
detected.
Eyes:
Pupils equal, round and reactive to light.
No discharge, conjunctivitis or scleral icterus.
Ears:
Clear external auditory canals. TM’s grey
bilaterally. No erythema or bulging.
Nose:
Normal pink mucosa, no discharge or blood
visible. Normal midline septum.
Throat:
Mouth: moist mucous membranes. No ulcer or
aphthous was seen.
Pharynx: Pharynx shows no erythema or
ulcerations. Normal movement of soft palate.
 Thorax Physical Examination

Chest Wall & Lung:

No increase of accessory muscles – no evidence
of increased work of breathing. Lungs have
rhonchi dominant in apexes in auscultation
bilaterally. Rhonchi will dissolve and relocate
with coughing.
No stridor, wheezes, crackles, or rubs. Good air
movement.

CV:
Normal S1 with normally split S2 on
respiration. No murmurs, gallops or rubs. Full
pulses in all extremities including strong
bilateral femoral pulses. Capillary refill less
than 2 sec.
Abdomen:
Soft, non-tender, non-distended.
Physical Examination
No noted splenomegaly. No masses.

Extremities
Clubbing is seen in all nails. No cyanosis or
edema. No gross deformities. Good skin
turgor with no tenting.
Summary:
Patient is a 20 y/o known
case of CF with several Hx
of hospitalization. She has
had exacerbated productive
coughs with green sputum
for 1 month.
The lab test shows sputum
culture positive for
pseudomonas.
In physical examination
generalized rhonchi with
dominancy in both apexes
is auscultated. Clubbing is
seen in all nails.
WBC 12700 PT 12.7
NEUT 80 PTT 30
LYMPH 19 INR 1.1
Hgb 12.7
MCV 76
plt 277
BUN 7.6
ESR 51
CRP 26
Cr 0.77
Ca 9.4
P 3.8
AST 33
ALT 11
ALKP 178
Na 139
K 3.8
 Source of History:
Patient’s Parents
Semi-reliable, Co-operative

Patient’s ID:
6.5-year-old girl, third born child of a
family with three children, From Tehran,
Living in Tehran

Chief Complaint:
Fever and UTI
 Presenting Illness:
Patient is a 6.5 y/o girl with recurrent
fever. Each year she has had 1-2 episodes
of fever each lasting 6-7 days from birth.
The second last episode of fever was 25
days ago which was controlled by
antipyretics. She hasn't had any
complaints since then until today when
she had another episode of
fever. Associated symptoms include
Lower Urinary Tract Symptoms such as
frequency, dysuria, urgency, urge
incontinence, and nocturnal enuresis.
Foul-smelling urine is also present, but
the color of urine has not changed.
 Presenting Illness:
On 18th of Khordad an abdominal
ultrasound was conducted for the
patient with the following result:
Normal size kidneys. Normal cortico-
medullary pattern. No evidence of
hydronephrosis or renal calculi. Normal
bladder thickness.
The last urinalysis was active and
positive for nitrite and had WBC=18-
20.
The last urine culture reports E.coli
infection.
 Past Medical History

Neonatal:
Third child of G4P3L3Ab1 mother, she was
delivered via C/S due to repeat. Mother had
pre-existing HTN which was controlled
during pregnancy by pharmacotherapy. The
delivery was uncomplicated. Born as a term
infant with GA=37 weeks and birth weight
of 3125g. As an infant patient was admitted
to NICU due to vague history of infection.
 Past Medical History

Past Hospitalizations:
At one year old the patient was admitted to
hospital with similar presentation (fever)

Immunizations:
Vaccination was fully completed according to
national protocol of vaccination.
Past Surgical History:
None

Allergy History
None
 Growth and Development

Growth:
Weight: 17 kg Height: 120 cm Z-score:-2

On growth charts there has been a growth failure

with an almost horizontal line.

Development:
Normal Development
:
 Drug History

No drug was used recently.

 Family History

Parents are relatives (Second Cousins)

The other two children are healthy.
HTN and Hypothyroidism in mother
General Appearance: Physical Examination
Patient is a thin girl, awake, alert and
oriented who answers questions and co-
operates. She is not ill or toxic. She is not in
distress.

Vital Sign:
T: 36.9
PR: 118
RR: 24
BP: 95/65

Skin:
Skin is not pale or icteric. No petechiae or
purpura was seen. No rashes or
pathological skin legions was observed.
 HEENT Physical Examination
Head & Neck:
Neck: No tracheal deviation. No decrease in
ROM. No lymphadenopathy, goiter or masses
detected.
Eyes:
Pupils equal, round and reactive to light.
No discharge, conjunctivitis or scleral icterus.
Ears:
Clear external auditory canals. TM’s grey
bilaterally. No erythema or bulging.
Nose:
Normal pink mucosa, no discharge or blood
visible. Normal midline septum.
Throat:
Mouth: moist mucous membranes. No ulcer or
aphthous was seen.
Pharynx: Pharynx shows no erythema or
ulcerations. Normal movement of soft palate.
 Thorax Physical Examination

Chest Wall & Lung:

No increase of accessory muscles – no evidence
of increased work of breathing. Lungs have
clear sounds in auscultation. No stridor,
wheezes, crackles, or rubs. Good air
movement.

CV:
Normal S1 with normally split S2 on
respiration. No murmurs, gallops or rubs. Full
pulses in all extremities including strong
bilateral femoral pulses. Capillary refill less
than 2 sec.
Abdomen:
Soft, non-tender, non-distended.
Physical Examination
No noted splenomegaly. No masses.
No CVA tenderness

Extremities:
No cyanosis or edema. No gross deformities.
Good skin turgor with no tenting.
Summary:
Patient is a 6.5 y/o girl with
history of recurrent fever
since birth who has
presented with another
episode of fever
accompanied with
frequency, urgency, urge
incontinence, and
nocturnal enuresis.
U/A was active, and U/C
showed E.coli growth.
No significant finding in
physical examination was
founded.
WBC 5800 U/A SG 1.022
NEUT 56.3 pH 6
LYMPH 32.3 WBC 2-3
Hgb 11.2 RBC 1-2
MCV 79.1
PLT 400
BUN 12.5
ESR 9
CRP 5
Cr 0.59
Na 138
K 3.8