IRON DEFICIENCY ANEMIA

Patient ProfileName : Bara’a Al-MomaniGender : Female Age : 23 yearsOccupation : Student Marital Status : SingleAddress : Irbid File Nom. :20102031064

Chief ComplaintIDA follow up

History of Present IllnessA 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 HistoryNo significant history

Allergy and Drug HistoryNone

Family HistoryNone

Physical ExaminationVitals: BP 130/89, Temp. 37.8, HR 80She looks well, and no signs of anemia is noticed

InvestigationsIn the previous visit her CBC was :Hb. : 11.2 g/dlMCV : 80 umFerritin: 6.2 ng/mlIn this visit her CBC is :Hb:13.5 g/dlMCV:85 umFerritin: 28 ng/ml

DiagnosisIron Deficiency Anemia

Management1. Ferrous sulphate for another 3 months .

Dyspepsia

Patient ProfileName : Khrestala Wael RashdanGender : female Age : 56 years oldMarital Status : MarriedAddress : Irbid File Nom. : 12934Date : 6/4/2015

Chief ComplaintEpigastric pain of 3 days duration.

History of Present IllnessA 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 HistoryNone

Family HistoryNone

Physical ExaminationPhysical examination reveals a fit, apparently healthy woman in no distress. The only abnormal finding is mild epigastric tenderness on palpation of the abdomen. And Murphy’s sign was negative

Management Plan1. Consider endoscopy.2. H.Pylori serology.3. Lansoprazole for 7 days4. Abdominal US to rule out GBS. 5. Follow up results

TONSILITIS

Patient ProfileName : Mayar Feras HayajnehGender : Female Age : 5 years oldAddress : Irbid File Nom. : 16585Date 8/4/2015

Chief ComplaintSore throat and fever since 3 days.

History of Present IllnessA 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 HistoryNo significant historyNo history of asthma

Allergy and Drug HistoryNone

Family HistoryNone

Physical ExaminationVitals : 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)

InvestigationsNone

DiagnosisBacterial Tonsilitis

Management1. Antibiotics2. Paracetamol3. Antihistamine

COMMON COLD

Patient ProfileName : Khaled Adel Al-SaloGender : Female Age : 20 yearsOccupation : Student Marital Status : SingleAddress : Irbid File Nom. : 20132030185Date :29/3/2015

Chief ComplaintSore throat and mild fever since 2 days.

History of Present IllnessA 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 HistoryNo significant history

Allergy and Drug HistoryNone

Family HistoryMother known case of asthma.

Physical ExaminationHe looks ill.On throat examination, there’s postnasal drip, enlarged red tonsils, with no exudate

InvestigationsNone

DiagnosisCommon cold (Flu-like illness)

Management1. Mucolytic syrup2. Decongestant3. Paracetamol

MIGRAINE

Patient ProfileName : Fadhilla AbbasGender : Female Age : 18 yearsOccupation : Student Marital Status : SingleAddress : Irbid

Chief ComplaintHeadache since last 2 hours.

History of Present IllnessA 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. There’s 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 HistoryKnown case of migraine diagnosed 2 years ago.

Allergy and Drug HistoryIbuprofen

Family History

None

Physical ExaminationShe looks ill.

InvestigationsNone

DiagnosisMigraine attack

Management1. Ibuprofen2. Diclofenac

TENSION HEADACHE

Patient ProfileName : Norhan Fwaz ShobakiGender : Female Age : 19 years oldOccupation : Student Marital Status : SingleAddress : Irbid File Nom. : 20142081006Date : 9/42015

Chief ComplaintHeadache and neck pain since 4 days.

History of Present IllnessA 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 HistoryFree

Allergy and Drug HistoryNo known history of allergy

Family HistoryMother diagnosed with DM and HTNGrandfather with DM and HTN

Physical ExaminationShe looks well.

InvestigationsNone

DiagnosisTension Headache

Management1. Paracetamol2. Myogesic3. Diclogesic gel

GASTROENTERITIS

Patient ProfileName : Eyhab Ahmad ShehadahGender : Male Age : 21 yearsOccupation : Student Marital Status : SingleAddress : Irbid File Nom.: 2011002505Date: 19/3/2015

Chief ComplaintDiarrhea and vomiting since 2 days.

History of Present IllnessA 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 : 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 HistoryNone

Allergy and Drug HistoryNone

Family HistoryNone

Physical ExaminationThe patient looks afebrile , No signs of dehydration, Abdomen is soft lax and no specific findings

InvestigationsNone

DiagnosisViral gastroenteritis

Management1. Oral Rehydration Solution 2. Antiemetic (domperidone)

INFLUENZA

Patient ProfileName : Sobri Faisol Mahmoud An-NayabatGender : Male Age : 17 years oldOccupation : Student Marital Status : SingleAddress : Irbid

Chief ComplaintFever, sore throat and cough since 12 hours.

History of Present IllnessA 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 HistoryNone

Allergy and Drug HistoryNone

Family HistoryNone

Physical ExaminationHe looks well.On throat examination, the throat appear erythematous.On auscultation, clear chest.

InvestigationsNone

DiagnosisInfluenza

Management1. Amoclan.2. Herbal cough syrup.

OTITIS MEDIA

Patient ProfileName : Bashar Hasan Abo-ShamatGender : Male Age : 19 years oldAddress : Irbid File Nom. :20122023084Date : 29/3/2015

Chief ComplaintFever and earache since 5 days.

History of Present IllnessA 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 HistoryNone

Family HistoryNone

Physical ExaminationVital sign : T=38.4, RR=20, HR=78He looks ill.On throat examination, there is tonsil enlargement and it appears erythematous.On otoscopy, left red tympanic membrane.On auscultation, clear chest.

InvestigationsNone

DiagnosisOtitis Media

Management1. Ceftriaxone2. Amoxicilin3. Clavulanic Acid

URINARY TRACT INFECTION

Patient ProfileName : Rema Sa’ad AlaweenGender : Female Age : 22 years oldMarital Status : singleAddress : Irbid File Nom. : 20112010435Date:29/3/2015

Chief ComplaintBurning sensation during urination of 5 days duration.

History of Present IllnessA 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 HistoryFree

Allergy and Drug HistoryNone

Family HistoryNone

Physical ExaminationVital sign : T=37, RR=14, HR=88Patient looks well.On abdominal examination, everything was normal except mild suprapubic tenderness.

InvestigationsDipstick urinalysis and culture

DiagnosisUrinary Tract Infection

Management1. Ciprofloxacine X 7D

MUSCLE SPASM(LOW BACK PAIN)

Patient ProfileName : Aysha AbdallahGender : Female Age : 19 yearsMarital Status : SingleAddress : Irbid File Nom. :20142040021 Date:2/4/2015

Chief ComplaintLow back pain of 2 days duration.

History of Present IllnessA 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. There’s 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 he’s 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 HistoryFree

Allergy and Drug HistoryNone

Family HistoryNone

Physical ExaminationHe 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.

InvestigationsNone

DiagnosisMuscle spasm

Management1. Myalgesic – muscle relaxant2. Paracetamol3. Counseling on avoidance of heavy weight lifting and rest.

Acne

Patient ProfileName : Anas Ibrahim ShormanGender : Male Age : 22 yearsMarital Status : SingleAddress : Irbid File Nom. : 20102024045Date :5/4/2015

Chief ComplaintSkin eruption getting worse over the past 3 monthes.

History of Present IllnessA 22-year-old male presents to the clinic with a long history of a facial and backeruption that has been getting worse progressively over the past 3 monthes. Some of thelesions 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 : 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 HistorySimilar picture of having low back pain because of heavy weight lifting.

Allergy and Drug HistoryNone

Family HistoryNone

Physical ExaminationThere are numerous comedomes, particularly on her forehead, pustules, papules, inflammatorylesions, cysts and atrophic scars There is sparing of the periorbital skin. And also the same on his back.InvestigationsNone

DiagnosisSever acne vulgaris

Management1. Zineryt ( Erythromycin-zinc complex)2. Doxycycline.

Note: The patient refused Isotretinoin because of its side effects.