IRON DEFICIENCY ANEMIA

Patient ProfileName: Nur AhmadGender: Female Age: 23 yearsOccupation: Student Marital Status: SingleAddress: Irbid

Chief ComplaintFatigue of 3 months duration

History of Present IllnessA 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 HistoryNo significant history

Allergy and Drug HistoryNone

Family HistoryNone

Physical ExaminationVitals: BP 130/89, Temp. 37.8, HR 102She looks well, very fine tremor, no audible murmurs, no respiratory soundsno ophthalmologic manifestations and no neck examination performed(hijab).

InvestigationsHb.: 9.8 g/dlMCV: 71 umMCH: 22.2 pgMCHC: 31.2 g/dlFerritin: 2.9 ng/ml

DiagnosisIron Deficiency Anemia

Management1. Ferrous sulphate 80mg1. Antidepressant SSRI Fluoxetine

GASTROESOPHAGEAL REFLUX (GERD)

Patient ProfileName: AhmadGender: Male Age: 21 years oldOccupation: Student Marital Status: SingleAddress: Irbid

Chief ComplaintHeartburn of 2 weeks duration.

History of Present IllnessA 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 HistoryNo significant history

Allergy and Drug HistoryNone

Family HistoryNonePhysical ExaminationHe looks well with normal or stable vital signsOn abdominal examination, everything was normal

InvestigationsNone

DiagnosisGastroesophageal Reflux (GERD)

Management1. Lifestyle modification :-Quit smoking-Avoid sleeping before 2 hours after eating-Reduce coffee intake 2.Proton Pump Inhibitor (PPI)

TONSILITIS

Patient ProfileName: Hala Mamoon BatainehGender: Female Age: 6 years oldAddress: Irbid

Chief ComplaintSore throat and fever since 12 hours.

History of Present IllnessA 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 HistoryNo significant historyNo history of asthma

Allergy and Drug HistoryNone

Family HistoryNone

Physical ExaminationVitals: T : 37.0, Wt :17.5kgShe 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)

InvestigationsNone

DiagnosisBacterial Tonsilitis

Management1. Antibiotics2. Paracetamol3. Antihistamine

COMMON COLD

Patient ProfileName: Aisyah Syakirah MustaffaGender: Female Age: 22 yearsOccupation: Student Marital Status: SingleAddress: Irbid

Chief ComplaintSore throat and mild fever since 2 days.

History of Present IllnessA 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 HistoryNo significant history

Allergy and Drug HistoryNone

Family HistoryMother known case of asthma.

Physical ExaminationShe looks ill.On throat examination, theres postnasal drip, no enlargement of tonsils, no exudate or redness of tonsils.

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. 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 HistoryKnown case of migraine diagnosed 2 years ago.

Allergy and Drug HistoryIbuprofen

Family HistoryNone

Physical ExaminationShe looks ill.

InvestigationsNone

DiagnosisMigraine attack

Management1. Ibuprofen2. Diclofenac

TENSION HEADACHE

Patient ProfileName: Nur Adibah HamdanGender: Female Age: 22 years oldOccupation: Student Marital Status: SingleAddress: Irbid

Chief ComplaintHeadache and neck pain since one day.

History of Present IllnessA 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 HistoryIron Deficiency Anemia

Allergy and Drug HistoryKnown case of eczema since 21 years old.Iron supplement

Family HistoryMother diagnosed with DM and HTNGrandfather with DM and HTN

Physical ExaminationShe looks well.

InvestigationsNone

DiagnosisTension Headache

Management1. Paracetamol2. Myogesic3. Diclogesic gel

VIRAL GASTROENTERITIS

Patient ProfileName: Muhammad SyarmineGender: Male Age: 21 yearsOccupation: Student Marital Status: SingleAddress: Irbid

Chief ComplaintDiarrhea and vomiting since 12 hours.

History of Present IllnessA 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 HistoryNone

Allergy and Drug HistoryNone

Family HistoryNone

Physical ExaminationHe looks ill and dehydrated. Dry mouth, No sunken eye, normal skin turgor, normal blood capillary refill.Abdomen soft and lax.

InvestigationsNone

DiagnosisViral gastroenteritis

Management1. IV bolus 1000ml2. Zantac3. Antiemetic

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: Mahmood JarrahGender: Male Age: 5 years oldAddress: Irbid

Chief ComplaintCough and fever since one day.

History of Present IllnessA 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 HistoryNone

Allergy and Drug HistoryNone

Family HistoryNone

Physical ExaminationVital sign : T=39.4, RR=20, HR=78He looks ill.On throat examination, there is tonsil enlargement and it appears erythematous.On otoscopy, bilateral red tympanic membrane.On auscultation, clear chest.

InvestigationsNone

DiagnosisOtitis Media

Management1. Ceftriaxone2. Amoxicilin3. Clavulanic Acid

URINARY TRACT INFECTION

Patient ProfileName: SarahGender: Female Age: 32 years oldMarital Status: MarriedAddress: Irbid

Chief ComplaintBurning sensation during urination of 3 days duration.

History of Present IllnessA 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 HistoryDiagnosed UTI 2 years ago

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

DiagnosisUrinary Tract Infection

Management1. Sulphamethoxazole / Trimethoprime

MUSCLE SPASM(LOW BACK PAIN)

Patient ProfileName: MuhammadGender: Male Age: 26 yearsOccupation: Worker at Conservation Department at JUSTMarital Status: SingleAddress: Irbid

Chief ComplaintLow back pain of one week duration.

History of Present IllnessA 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 HistorySimilar picture of having low back pain because of heavy weight lifting.

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.On raising leg test, it was negative.

InvestigationsNone

DiagnosisMuscle spasm

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