Ministry of Healthcare of the Republic of Moldova

State University of Medicine and Pharmacy “ Nicolae Testemițanu”

Republic of Moldova

Infectious Diseases Department

Pediatric Infectious Diseases Clinic

Medical Report

Presented by: Sabbah Ahmad

Group: 1443
presented to doctor:Alexeev Tatiana
19.11.2019
I. General Data

Basic Information
- Name: dumitru noroc
- Age: 17
- Gender: male
- address:, Chisinau.
- health insurance: Yes (CNAM)
- Date and time of admission: 13/11/2019 22:55
- Diagnosis at hospital admission: Acute gastroenteritis
- Basic and concomitant clinical diagnosis: shigellosis

Presumptive diagnosis: shigellosis

II. Hospital admission complains

Complains : Disoriented patient ,Fever (38-39 degrees), diarrhea ; severe,

continuous abdominal pain in the umbilical region without radiation
,headache and chills

III. The main patient complaints in the curation day

Fever ,diarrhea , Abdominal pain.

IV. History of present disease (Anamnesis Morbii)

Disease onset- acute, sudden onest of yellow diarrhea followed by fever , fatigue
and severe abdominal pain

Disease evolution- acute disease without any specific etiology

V. Epidemiological anamnesis

1. Sources of infection: there’s no specific

2. Specify routes of infection (disease pathways): feco-oral route transmission

due to low hygiene

3. vaccines- up to date

4. The patient has had no contact with patients with tuberculosis or STDs

VI. The past patient’s history (Anamnesis vitae)

The patient was born at 38 weeks of gestation by uncomplicated vaginal delivery ,

with an APGAR score of 9.

The patient with normal Psycho-physical development for his age.

he live with his family, father ,mother and one 21 years old sister which is at
university , the are in moderate economic status .

he plays gymnastics , eats healthy and do well at school.

Past Illnesses :

- Cataract at 5 years old .

- No history of Children's infectious diseases
- No Operations, injuries, birth trauma or neurological affections.
- No family history .

VII. Allergic anamnesis:

The patient and his family members have no allergies.

VIII. Bad habits
No bad habits as he told us

IX. Physical Examination in the curation day

a)Inspection :

General condition: disoriented

Consciousness – conscious

Temperature: 38.5

Posture of patient : passive

Constitution: Asthenic. Physical growth- accelerated, body weight - 42

Skin: color- pale

skin turgidity is present, skin elasticity is decreased, dehydrated, cold;

Skin rash:

No skin rashes present

Visible mucosa: Sclerae- Normal; conjuctivae- Normal

Hair-Normal

Subcutaneous adipose tissue: Nutrition: satisfactory

Oedemas: Not present.

Head: Normal

Neck: Normal

The lymph node- Not palpable

Salivary Glands: Normal

Muscular system developed satisfactorily

The osteo-articular system: joints- Pale, normal configuration, edema is absent,
active and passive movements are normal, no pain on palpation.

A. Respiratory System

Complains:

No complains

Physical data:
Shape variations of the thorax: None
Breathing: Normal.
Palpation- elastic, no painful palpation; vibrations: Normal
Percussion: comparative percussion- full, bright, comparable on both halves of
the thorax.

Auscultation: clear alveolar breathing.

B. Cardiovascular System :

Complains: No complaints

Palpation- the beat of the heart apex is felt in the 4th - 5th intercostal space on
the medial side of the midclavicular line.

Percussion:

Intercosta Right Left

ls
I Cardiac dullness is not detected
II The vascular pedicle not exceed
the lateral border of the sternum
III At a distance of 1 cm from the
right border of the sternum
IV At a distance of 0.5 cm from the
right edge of the sternum
Cardiac dullness is not
detected
The vascular pedicle not
exceed the lateral border of
the sternum
At a distance of 1.5 cm from
the left border of the sternum
2 cm from the lateral border
of the sternum
 V At the right lateral border of the On the midclavicular line at
sternum the point of the apex beat

Auscultation : 96, 100/70;

Regular rate and rhythm , Regular S1,S2 , No murmurs was heard, At the
following auscultation points:

The Mitral valve – At the area of the apex beat.

The Aortal – In the second intercostal space , to the right of the sternum.

The Pulmonary trunk – In the second intercostal space , to the left of the sternum.

The Tricuspid valve – At the lower part of the sternum , near its junction with the
xiphoid process.

Point of Erb – At the left of the sternum between the 3rd and 4th intercostal space.

Inspection of the peripheral vessels : Carotid pulse normal.

C. Digestive System:

Complains: abdominal pain in umbilical region, no irradiation, , severe intensity,

no dependence on what patient ate.

Nausea and vomiting- nausea is present.

Appetite: loss of appetite. Water intake during 24 hours is normal, painless

deglutition; No Bloating or tenesmus. Body Weight: 42Kg

Physical exam:

- oral cavity – dry

- Tongue – dry
- Gums – normal

- Teeth – normal

- Oropharynx – normal

- Abdomen- normal

- superficial palpation normal

-deep palpation : normal

Percussion: the abdominal wall is firm; percussion produces tympanic sound

Liver:

Edge- rounded

Consistency: soft

Liver percussion Kurlov method:

-Between 1st and 2nd points – 9 cm

-Between 3rd and 4th points – 8 cm

-Between 3rd and 5th points – 7 cm

Spleen: normal

Pancreas- no pain in the pancreatic points.

D. Urinary System

Lumbar or blader pain - Absent

Mictions- normal

Color light color, transparent.

Physical data:

Palpation – normal.

Percution – Pasternatki sign negative;

 E. Endocrine system:

Complains- thirst, loss of appetite

Inspection- normal

Palpation- normal.

F. Nervous System

Mental condition: conscious, normal spatial orientation, patient’s mood is good,

attention is normal, emotions are present. The sleep: deep, quiet. Sensory
peculiarities - normal. Meningian signs – negative. Seizures - absent

X. Presumptive Diagnosis

Based on the patient complaints (Fever, diarrhea , abdominal pain – pain

syndrome, Loss of appetite, Fatigue, dizziness – Asthenic syndrome,
anamnestic of the illness, life, epidemiologic, allergy), physical exam (Dry skin
and mouth, Weight loss, fatigue, asthenic), we can establish the presumptive
diagnosis of shigellosis

XI. Laboratory and instrumental investigations

We need to order-

Complete blood count

Stool culture

XIV. Clinical Diagnosis- we didn’t receive the result of the test that we ordered
so there is no confirmed diagnosis

Persumbtive diagnosis- shigellosis

XV. The Treatment plan

 Rest Regime - full rest

 Diet – Fluids to stay hydrated
 Medications –
Etiological- ciprofloxacin 15 mg\kg twice daily for 3 days
Antiemetic drugs for fever