Clinical Clerk

Name: Nahyan Asif

BM:23, Roll: 69, Batch: F
Bed # 10, PNPW
PARTICULARS OF THE PATIENT:

- NAME : Yasir

- AGE: 5 YEARS

- SEX: Male

- Religion: Islam

- ADDRESS: Mohammedpur

- D.O.A: 16/05/11

- D.O.E: 16/05/11

- Admission: Paediatrics Non-paying Ward

CHIEF COMPLAINTS

1) Abdominal pain- 9 days

2) Fever- 8 days

H/O PRESENT ILLNESS

- As per the statement obtained from my patient’s mother, he was

relatively well 4 months ago. Then an abdominal pain arose 4 months
ago, that gradually intensified and as of 9 days ago became so severe
as to seek medical assistance. The pain was localised in the umbilical
region and wasn’t associated with any other symptoms. Abdomen was
never distended, but as of 9 days ago, the pain became severe enough
to make him cry. So he visited a doctor in the outpatient department of
Bangladesh Medical College Hospital; and upon taking the prescribed
medicine his pain subsided.

- However, the next day he developed a fever, recorded by his mother to

be 100oF; so they returned to the same doctor at Bangladesh Medical
College Hospital, and took the prescribed medicine. Despite the
medicine, his temperature dropped a little for a few hours, never
touching the baseline and returned to a high temperature once again.
Fever was associated with shivering and sweating. So once again my
patient visited the same doctor, who then suggested performing some
tests (CBC, Chest X-Ray, Test for Typhoid), the mother did so and
returned with the results to the doctor who suggested admitting him
into the hospital.
 H/O PAST ILLNESS

- At the age of 2 months, my patient developed a urinary tract infection,

doctors suggested circumcising him would solve the issue, so this was
done and he was cured

- At the age of 6 months, he had diarrhoea, that subsided within 5 days

upon taking prescribed medications from a doctor

- From the age of 6 months- 2.5 years, he suffered from Pneumonia that
was managed with the help of the doctor’s prescribed medicine

BIRTH HISTORY

- Antenatal: Mother suffered from loss of appetite throughout her entire

gestational period. She would also vomit 2-3 times every month,
vomitus was scanty in amount and contained undigested food particles
(usually rice) .Vomiting was not associated with any other symptoms.
She didn’t take any medicine for this and the problem resolved on its
own soon after she gave birth. Despite the vomiting mother tried to
maintain a balanced diet during the pregnancy.

- Natal: Birth was 1 month delayed. Delivery took place at a hospital , via
Caesarean section (my patient has a twin)

- Postnatal: no jaundice, septicaemia, convulsion or delayed crying

recorded. Birth weight was low (1.5 kg), so he was kept in the Intensive
Care Unit for 5 days. Then when doctors were satisfied with his ability
to suckle, he was discharged.

FEEDING HISTORY

- My patient was fed breast milk for the first 2 months of his life. He was
then fed powdered milk till the age of 4 years. The mother would also
occasionally feed him Khichuri when he was 6 months old, for around 2
months, then she fed them a wet rice bolus between the ages of 6-12
months.

- My patient since birth has had a very poor appetite, not wanting to
suckle breast milk as a baby and even now he isn’t at all keen on
 eating food; thus feeding him has been unusually difficult from birth till
now.

IMMUNISATION HISTORY

- Immunisation is up to date

DEVELOPMENTAL HISTORY

- He started to speak in short sentences at a late age of 1.5 years, other

than that development was normal.

DRUG HISTORY

- When he had pneumonia, he was treated with Antibiotics and given an

Injection the name of which the mother cannot recall

- When he had diarrhoea, he was treated with Antibiotics and when it got
serious, he was hospitalised

- 3 days ago, when he developed the fever, he was given

o “Extra”

o “Cefixime Trihydrate” : 1.5 teaspoon, twice a day

FAMILY HISTORY

- No recorded history of these symptoms in neither immediate nor

extended family members of either side of the family. Marriage was
non-consanguinal.

- Patient has a nuclear family that consists of parents, the eldest son,
aged 20 years, a 16 year old daughter and then 5 year old twins. My
patient is the elder twin brother.

- The younger twin, had a fever 4 months ago that subsided upon taking
the prescribed antibiotics.

- Father has been suffering from headache and uneasiness in the ear for
the past 1 month and is expected to visit the doctor soon.
- The daughter removed a tumour from the breast 1 month ago from
Bangladesh Medical College Hospital, she is otherwise in good health

- Elder brother is in good health and has no recorded history of any

illness

- Mother is in good health

SOCIO-ECONOMIC HISTORY

- Father works and mother looks after the children.