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IRON DEFICIENCY ANEMIA

Patient Profile
Name
: Baraa Al-Momani
Gender
: Female
Age
: 23 years
Occupation : Student
Marital Status : Single
Address
: Irbid
File Nom.
:20102031064
Chief Complaint
IDA follow up
History of Present Illness
A 23-year old female known case of IDA since 3 months and on iron oral supplements (2 tablets
per day) came back for regular follow up.
3 months ago she started to complain from general fatigue and dizziness. On further questioning
she denied to be in depressed mode or if there is lose of interest.
Her menstrual cycle is regular changing about 7 pads/day.
After receiving the iron supplements her condition is improved.
Review of System
-General
: No change in appetite.
-GI
: No diarrhea, no abdominal pain and no vomiting.
-CVS
: No palpitations and no chest pain
-RS
: No SOB, no wheezing, no cough, no sore throat, no nasal congestion
-UGS
: Regular period
Past Medical History
No significant history
Allergy and Drug History
None
Family History
None

Physical Examination
Vitals: BP 130/89, Temp. 37.8, HR 80
She looks well, and no signs of anemia is noticed
Investigations
In the previous visit her CBC was :
Hb.
: 11.2 g/dl
MCV : 80 um
Ferritin: 6.2 ng/ml
In this visit her CBC is :
Hb:13.5 g/dl
MCV:85 um
Ferritin: 28 ng/ml
Diagnosis
Iron Deficiency Anemia
Management
1 Ferrous sulphate for another 3 months .

Dyspepsia
Patient Profile
Name
: Khrestala Wael Rashdan
Gender
: female
Age
: 56 years old
Marital Status : Married
Address
: Irbid
File Nom.
: 12934
Date
: 6/4/2015
Chief Complaint
Epigastric pain of 3 days duration.
History of Present Illness
A 56-year old female comes complaining of epigastric of 2 weeks duration.
She describes the pain as a dull, gnawing ache. The pain sometimes wakes
her at night, is relieved by food, with no radiation.
There is no heartburn, no vomiting but she feels nauseated also there is no
change in bowel habit or abdominal distension. Also there is no dysphagia
She had a similar but milder episode about 4 months ago, which was
treated with omeprazole.
Review of System
-General
: No loss of appetite, no weight loss.
-GI
: No diarrhea, no abdominal pain and no vomiting.
-CVS
: No palpitations and no chest pain
-RS
: No SOB, no wheezing, no cough, no sore throat, no nasal congestion

Allergy and Drug History


None
Family History

None
Physical Examination
Physical examination reveals a fit, apparently healthy woman in no distress.
The only abnormal finding is mild epigastric tenderness on palpation of the
abdomen. And Murphys sign was negative

Management Plan
1. Consider endoscopy.
2. H.Pylori serology.
3. Lansoprazole for 7 days
4. Abdominal US to rule out GBS.
5. Follow up results

TONSILITIS
Patient Profile
Name
: Mayar Feras Hayajneh
Gender
: Female
Age
: 5 years old
Address
: Irbid
File Nom.
: 16585
Date
8/4/2015
Chief Complaint
Sore throat and fever since 3 days.
History of Present Illness
A 5-year old child comes complaining of sore throat and fever since 3 days. The sore throat is
accompanied by nasal discharge with no cough ,also she had fever which was measured at home
and it was 38.6 orally. There are no skin rash, shortness of breath, audible sound during
inhalation and exhalation, vomiting, diarrhea or any urinary symptoms.
2 days ago she came to the center with the same complains and shw was treated with Amoclan
and anti-pyratics but with little response.
Past Medical History
No significant history
No history of asthma
Allergy and Drug History
None
Family History
None
Physical Examination
Vitals : T : 38.5, Wt :17.5kg

She looks pale.


On examination of throat, there are an enlarged exudative tonsil with follicle.
On lymph node palpation, there is bilateral enlargement of anterior cervical lymph node which
are tender about 1-2cm in size.
(5/5 Strep Score)
Investigations
None

Diagnosis
Bacterial Tonsilitis
Management
1. Antibiotics
2. Paracetamol
3. Antihistamine

COMMON COLD
Patient Profile
Name
: Khaled Adel Al-Salo
Gender
: Female
Age
: 20 years
Occupation : Student
Marital Status : Single
Address
: Irbid
File Nom.
: 20132030185
Date
:29/3/2015
Chief Complaint
Sore throat and mild fever since 2 days.
History of Present Illness
A 20-year old male patient comes complaining of sore throat and mild fever since 2 days.
Associated with chills, nausea, headache and tiredness. There are runny nose, blocked nose,
change in voice and cough. There are no shortness of breath, no audible sound, no chest pain and
no ear pain.
Review of System
-General
: No change in appetite, no weight loss, general weakness.
-CVS
: No chest pain, no palpitation.
-UGS
: No burning in micturition, no change in urine color, frequency or amount of
urine. No urgency.
Past Medical History
No significant history
Allergy and Drug History
None

Family History
Mother known case of asthma.
Physical Examination
He looks ill.
On throat examination, theres postnasal drip, enlarged red tonsils, with no exudate
Investigations
None

Diagnosis
Common cold (Flu-like illness)
Management
1. Mucolytic syrup
2. Decongestant
3. Paracetamol

MIGRAINE
Patient Profile
Name
: Fadhilla Abbas
Gender
: Female
Age
: 18 years
Occupation : Student
Marital Status : Single
Address
: Irbid
Chief Complaint
Headache since last 2 hours.
History of Present Illness
A 18-years old female patient known case of migraine, comes complaining of unilateral
headache since last 2 hours aggravated by stress and relieved by rest and analgesic. The
headache last for 2 hours and associated with photophobia. Theres no phonophobia, no nausea,
no vomiting, no fever, no preceeded aura. The headache is not related to meals.
Review of System
-General
: General weakness.
-CVS
: No palpitation, no chest pain.
-RS
: No SOB, no sore throat, no nasal discharge, no cough.
-GI
: No diarrhea, no constipation, no abdominal pain.
Past Medical History
Known case of migraine diagnosed 2 years ago.
Allergy and Drug History
Ibuprofen
Family History

None
Physical Examination
She looks ill.
Investigations
None
Diagnosis
Migraine attack
Management
1. Ibuprofen
2. Diclofenac

TENSION HEADACHE
Patient Profile
Name
: Norhan Fwaz Shobaki
Gender
: Female
Age
: 19 years old
Occupation : Student
Marital Status : Single
Address
: Irbid
File Nom.
: 20142081006
Date
: 9/42015
Chief Complaint
Headache and neck pain since 4 days.
History of Present Illness
A 22-years old female patient comes complaining of headache and neck pain since 4 days. The
headache mainly at the frontal site and occipital nuchal. Characterized by feeling of band like
squeezing around the head. The headache is preceded with stress which intermittent in pattern
and usually last for 1 hours. It usually slightly relieved by paracetamol. The neck pain dull in
nature and localized at the upper part concentrated at the left site. No blurred vision, no
vomiting, not related to meals.
No history of head trauma
Review of System
-General
: Fatigue, no loss of appetite.
-CVS
: No palpitation, no chest pain.
-RS
: No SOB, no sore throat, no nasal discharge, no cough.
-GI
: No diarrhea, no constipation, no abdominal pain.
-UGS
: No burning in micturition, no change in urine color, frequency or amount of
urine. No urgency.

Past Medical History


Free
Allergy and Drug History
No known history of allergy

Family History
Mother diagnosed with DM and HTN
Grandfather with DM and HTN
Physical Examination
She looks well.
Investigations
None
Diagnosis
Tension Headache
Management
1. Paracetamol
2. Myogesic
3. Diclogesic gel

GASTROENTERITIS
Patient Profile
Name
: Eyhab Ahmad Shehadah
Gender
: Male
Age
: 21 years
Occupation : Student
Marital Status : Single
Address
: Irbid
File Nom.: 2011002505
Date: 19/3/2015
Chief Complaint
Diarrhea and vomiting since 2 days.
History of Present Illness
A 21-years old male patient comes complaining of diarrhea and vomiting since 2 days.
He had diarrhea for 8 times. It was watery and there are absence of mucus and blood in the
diarrhea. The diarrhea is associated with heart burn, abdominal discomfort and mild pain at
epigastric region.
He had vomiting only once before presented to the primary care. He described it as projectile
vomiting. It was watery with no relation to meal. No mucus or blood present in the vomitus. He
ate spicy food 8 hours prior to appearance of symptoms. There is no history of recent travel.
Review of System
-General
: Loss of appetite, general weakness.
-CVS
: No palpitation, no chest pain.
-Neurological : Headaches

-UGS
-RS

: No burning in micturition, no change in urine color, frequency or amount of


urine. No urgency.
: No SOB, no sore throat, no cough, no nasal discharge.

Past Medical History


None
Allergy and Drug History
None
Family History
None
Physical Examination
The patient looks afebrile , No signs of dehydration, Abdomen is soft lax and no specific
findings
Investigations
None
Diagnosis
Viral gastroenteritis
Management
1. Oral Rehydration Solution
2. Antiemetic (domperidone)

INFLUENZA
Patient Profile
Name
: Sobri Faisol Mahmoud An-Nayabat
Gender
: Male
Age
: 17 years old
Occupation : Student
Marital Status : Single
Address
: Irbid
Chief Complaint
Fever, sore throat and cough since 12 hours.
History of Present Illness
A 17 years old male patient come complaining of fever, sore throat and cough since 12 hours.
The cough is production with white sputum. The complaints also associated with runny nose and
knee pain. There is no history of trauma that may relate to the knee pain.
Review of System
-General
: General weakness.
-CVS
: No palpitation, no chest pain.
-Neurological : Headaches
-UGS
: No burning in micturition, no change in urine color, frequency or amount of
urine. No urgency.
-GIT
: No vomiting, no diarrhea, no constipation, no abdominal pain.
Past Medical History
None

Allergy and Drug History


None
Family History
None
Physical Examination
He looks well.
On throat examination, the throat appear erythematous.
On auscultation, clear chest.

Investigations
None
Diagnosis
Influenza
Management
1. Amoclan.
2. Herbal cough syrup.

OTITIS MEDIA
Patient Profile
Name
: Bashar Hasan Abo-Shamat
Gender
: Male
Age
: 19 years old
Address
: Irbid
File Nom.
:20122023084
Date
: 29/3/2015
Chief Complaint
Fever and earache since 5 days.
History of Present Illness
A 19-years old male patient complaining of fever and earache since 5 day.The fever was coming
as intermittent episodes without specific timing, slightly relived by antipyratics but there is no
chills or rigors. He also complained from pain in his left ear but no discharge. Also he had a
reproductive cough is associated with sore throat and. There are no shortness of breath, nasal
discharge, nasal blockage or associated chest pain.
Review of System
-General
: General weakness.
-CVS
: No palpitation, no chest pain.
-Neurological : No headaches
-UGS
: No burning in micturition, no change in urine color, frequency or amount of
urine. No urgency.
-GIT
: No diarrhea, no constipation, no abdominal pain, no abdominal distension.
Past Medical History

None
Allergy and Drug History
None
Family History
None
Physical Examination
Vital sign : T=38.4, RR=20, HR=78
He looks ill.
On throat examination, there is tonsil enlargement and it appears erythematous.
On otoscopy, left red tympanic membrane.
On auscultation, clear chest.
Investigations
None
Diagnosis
Otitis Media
Management
1. Ceftriaxone
2. Amoxicilin
3. Clavulanic Acid

URINARY TRACT INFECTION


Patient Profile
Name
: Rema Saad Alaween
Gender
: Female
Age
: 22 years old
Marital Status : single
Address
: Irbid
File Nom. : 20112010435
Date:29/3/2015
Chief Complaint
Burning sensation during urination of 5 days duration.
History of Present Illness
A 22-years old male patient comes complaining of burning sensation during micturition and
increase in frequency of 5 days duration. She was doing well prior to the appearance of the
symptoms.She has no fever, no flank pain, no vomiting, no nausea, no blood in urine and
suprapubic pain.
Review of System
-General
: No change in appetite, no general weakness.
-CVS
: No palpitation, no chest pain.
-Neurological : No headaches
-RS
: No SOB, no sore throat, no cough, no nasal discharge.
-GIT
: No diarrhea, no constipation, no abdominal distension.

Past Medical History


Free
Allergy and Drug History
None
Family History
None
Physical Examination
Vital sign : T=37, RR=14, HR=88
Patient looks well.
On abdominal examination, everything was normal except mild suprapubic tenderness.

Investigations
Dipstick urinalysis and culture
Diagnosis
Urinary Tract Infection
Management
1. Ciprofloxacine X 7D

MUSCLE SPASM
(LOW BACK PAIN)
Patient Profile
Name
: Aysha Abdallah
Gender
: Female
Age
: 19 years
Marital Status : Single
Address
: Irbid
File Nom.
:20142040021
Date:2/4/2015
Chief Complaint
Low back pain of 2 days duration.
History of Present Illness
A 19-years old male comes complaining of low back pain since 2 days ago which was moderate,
intermittent, progressive, no diurnal variation, aggravated by walking or standing for a long time
and relieved slightly by rest. The pain is not associated with any urinary symptoms or defecation.
Theres no pain at the other site. Patient started to take paracetamol and he felt some relieved, but
after few hours, the pain goes back to the same intensity. This is not the first time hes having the

same kind of problem. She is with no other chronic illness and his work involves weight lifting
in a frequent manner.
Review of System
-General
: No change in appetite, nogeneral weakness.
-CVS
: No palpitation, no chest pain.
-Neurological : No headaches
-UGS
: No burning in micturition, no change in urine color, frequency or amount of
urine. No urgency.
-RS
: No SOB, no sore throat, no cough, no nasal discharge.
-GIT
: No vomiting, no diarrhea, no constipation, no abdominal pain, no abdominal
distension
Past Medical History
Free
Allergy and Drug History
None
Family History
None
Physical Examination
He looks well with stable vital signs.
Upon examination of lower back, there was some tenderness with some rigidity in the
paraspinous area.
On raising leg test, it was negative.
Investigations
None
Diagnosis
Muscle spasm
Management
1. Myalgesic muscle relaxant
2. Paracetamol
3. Counseling on avoidance of heavy weight lifting and rest.

Acne
Patient Profile
Name
: Anas Ibrahim Shorman
Gender
: Male
Age
: 22 years
Marital Status : Single
Address
: Irbid
File Nom.
: 20102024045
Date
:5/4/2015
Chief Complaint
Skin eruption getting worse over the past 3 monthes.
History of Present Illness
A 22-year-old male presents to the clinic with a long history of a facial and
back
eruption that has been getting worse progressively over the past 3 monthes.
Some of the
lesions on her face and back are painful at times and sometimes heal with
scarring and depegmented spots. His GP had prescribed several prolonged
courses of Contactubex with little benefit.
Review of System
-General
: No change in appetite, nogeneral weakness.
-CVS
: No palpitation, no chest pain.
-Neurological : No headaches

-UGS
-RS
-GIT

: No burning in micturition, no change in urine color, frequency or amount of


urine. No urgency.
: No SOB, no sore throat, no cough, no nasal discharge.
: No vomiting, no diarrhea, no constipation, no abdominal pain, no abdominal
distension

Past Medical History


Similar picture of having low back pain because of heavy weight lifting.
Allergy and Drug History
None
Family History
None
Physical Examination
There are numerous comedomes, particularly on her forehead, pustules,
papules, inflammatory
lesions, cysts and atrophic scars There is sparing of the periorbital skin. And
also the same on his back.
Investigations
None
Diagnosis
Sever acne vulgaris
Management
1. Zineryt ( Erythromycin-zinc complex)
2. Doxycycline.
Note: The patient refused Isotretinoin because of its side effects.