IRON DEFICIENCY ANEMIA

Patient Profile
Name
: Nur Ahmad
Gender
: Female
Age
: 23 years
Occupation : Student
Marital Status : Single
Address
: Irbid
Chief Complaint
Fatigue of 3 months duration
History of Present Illness
A 23-year old female previously healthy, presented with fatigue for 3 months. It was not relieved
by rest or sleep. Fatigue was associated with depression, loss of interest in daily activities,
difficult to concentrate, dizziness, and headache.
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 102
She looks well, very fine tremor, no audible murmurs, no respiratory sounds
no ophthalmologic manifestations and no neck examination performed(hijab).

Investigations
Hb.
: 9.8 g/dl
MCV : 71 um
MCH : 22.2 pg
MCHC: 31.2 g/dl
Ferritin: 2.9 ng/ml
Diagnosis
Iron Deficiency Anemia
Management
1 Ferrous sulphate 80mg
2 Antidepressant SSRI Fluoxetine

GASTROESOPHAGEAL REFLUX (GERD)

Patient Profile
Name
: Ahmad
Gender
: Male
Age
: 21 years old
Occupation : Student
Marital Status : Single
Address
: Irbid
Chief Complaint
Heartburn of 2 weeks duration.
History of Present Illness
A 21-year old male comes complaining of heartburn of 2 weeks duration. This problem happened
mainly after taking meals. Sometimes, the heartburn is associated with food regurgitation which
happened just once or twice in these 2 weeks duration. There is no diarrhea, no constipation, no
melena, no hematochezia, no epigastric pain, no weight loss, and no difficulty in swallowing.
The patient said that heartburn prevented him from sleeping. The heartburn is aggravated by
lying down and relieved by using antacids.
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
-Neurological : No headaches

Past Medical History

No significant history
Allergy and Drug History
None
Family History
None
Physical Examination
He looks well with normal or stable vital signs
On abdominal examination, everything was normal

Investigations
None
Diagnosis
Gastroesophageal Reflux (GERD)
Management
1. Lifestyle modification :
-Quit smoking
-Avoid sleeping before 2 hours after eating
-Reduce coffee intake
2. Proton Pump Inhibitor (PPI)

TONSILITIS
Patient Profile
Name
: Hala Mamoon Bataineh
Gender
: Female
Age
: 6 years old
Address
: Irbid
Chief Complaint
Sore throat and fever since 12 hours.
History of Present Illness
A 6-year old child comes complaining of sore throat and fever since 12 hours. The sore throat is
accompanied by nasal discharge with no cough. There are no skin rash, shortness of breath,
audible sound during inhalation and exhalation, vomiting, diarrhea or any urinary symptoms.
Review of System
-General
: No weight loss, no loss of appetite.
-GI
: No abdominal pain, no constipation.
Past Medical History
No significant history
No history of asthma
Allergy and Drug History
None
Family History
None
Physical Examination
Vitals : T : 37.0, Wt :17.5kg
She looks pale.
On examination of throat, there are an enlarged tonsil with follicle/polyps.
On lymph node palpation, there is bilateral enlargement of anterior cervical lymph node which
are tender about 1-2cm in size.
(4/5 Strep Score)
Investigations
None

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

COMMON COLD
Patient Profile
Name
: Aisyah Syakirah Mustaffa
Gender
: Female
Age
: 22 years
Occupation : Student
Marital Status : Single
Address
: Irbid
Chief Complaint
Sore throat and mild fever since 2 days.
History of Present Illness
A 22-year old female 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
She looks ill.
On throat examination, theres postnasal drip, no enlargement of tonsils, no exudate or redness of
tonsils.
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
: Nur Adibah Hamdan
Gender
: Female
Age
: 22 years old
Occupation : Student
Marital Status : Single
Address
: Irbid
Chief Complaint
Headache and neck pain since one day.
History of Present Illness
A 22-years old female patient comes complaining of headache and neck pain since one day. 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 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.
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
Iron Deficiency Anemia
Allergy and Drug History
Known case of eczema since 21 years old.
Iron supplement
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

VIRAL GASTROENTERITIS
Patient Profile
Name
: Muhammad Syarmine
Gender
: Male
Age
: 21 years
Occupation : Student
Marital Status : Single
Address
: Irbid
Chief Complaint
Diarrhea and vomiting since 12 hours.
History of Present Illness
A 21-years old male patient comes complaining of diarrhea and vomiting since 12 hours.
He had diarrhea for 15 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 3 times before presented to the primary care. He described it as projectile
vomiting. T 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
: 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.
Past Medical History
None
Allergy and Drug History
None
Family History
None
Physical Examination

He looks ill and dehydrated. Dry mouth, No sunken eye, normal skin turgor, normal blood
capillary refill.
Abdomen soft and lax.
Investigations
None
Diagnosis
Viral gastroenteritis
Management
1. IV bolus 1000ml
2. Zantac
3. Antiemetic

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
: Mahmood Jarrah
Gender
: Male
Age
: 5 years old
Address
: Irbid
Chief Complaint
Cough and fever since one day.
History of Present Illness
A 5-years old children complaining of productive cough and fever since one day. He also
complained about vomiting that usually happen after episode of cough. The cough is associated
with sore throat and ear pain without discharge. 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=39.4, RR=20, HR=78
He looks ill.
On throat examination, there is tonsil enlargement and it appears erythematous.
On otoscopy, bilateral 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
: Sarah
Gender
: Female
Age
: 32 years old
Marital Status : Married
Address
: Irbid
Chief Complaint
Burning sensation during urination of 3 days duration.
History of Present Illness
A 32-years old male patient comes complaining of burning sensation during micturition and
increase in frequency of 3 days duration. She was doing well prior to the appearance of the
symptoms. She has history of UTI 2 years ago. 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
Diagnosed UTI 2 years ago
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

Diagnosis
Urinary Tract Infection
Management
1. Sulphamethoxazole / Trimethoprime

MUSCLE SPASM
(LOW BACK PAIN)
Patient Profile
Name
: Muhammad
Gender
: Male
Age
: 26 years
Occupation : Worker at Conservation Department at JUST
Marital Status : Single
Address
: Irbid
Chief Complaint
Low back pain of one week duration.
History of Present Illness
A 26-years old male comes complaining of low back pain since a week 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. He is smoker 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
Similar picture of having low back pain because of heavy weight lifting.
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.
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.