Medical Case Report

Running head: MEDICAL CASE REPORT
MEDICAL CASE REPORT
Name of the Student:
Name of the University:
Author Note:

1MEDICAL CASE REPORT
Medical Case Report:
Name: Noel Smith
Age: 11 months
Sex: Male
Address of Parents: 43 Kerma Crescent, POTTERY ESTATE, NSW
Date and Time of History and Physical Exam: 15/03/19, 14:00 hours
Chief Complaint: ‘Eruption of rashes within the diaper region’
History:
Perinatal History: Born to 26 y/o mother, who was under prenatal care since the first
trimester. No prior history of alcohol or drug use during pregnancy.
Mother refers she or the father do not have Diabetes and that she experienced no
complications during her pregnancy
The pregnancy had been uneventful and the baby was born through vaginal delivery
The mother informs to have breast fed the baby only for 2 months
Development: Normal development with respect to the age
 The baby can sit without support
 Displays a social smile
 Can babble
 Has got his first tooth
 Can walk by holding onto furniture for support
Social Development: Normal. The baby is considerably attached to the parents. On asking
questions, the baby is able to respond ‘Yes’ and ‘No’.
Family: The baby stays with his parents Mitchelle (Mother,26 y/o) and Mark (Father,30
y/o). Mitchelle works as a teacher in Aberdeen School and Mark works as an assistant
advocate in a Law firm. The baby is taken care of by Martha (32 y/o) a domestic helper

2MEDICAL CASE REPORT
when the parents attend work. Mitchelle and Mark do not have any genetic disorders but
due to excessive work pressure, Mark has been diagnosed with hypertension. Mitchelle
reports to be suffering from post-partum depression after the birth of Noel. However, she
states that resuming her job has helped her in keeping herself occupied. Mitchelle reports
that she has never consulted professional help for her depression but follows some blogs
online. The medical history of the parents reveal no known allergies.
History of grandparents: Unknown
Immunization:
 The medical history of the baby reveals that the baby is immunised with vaccines
against Diphtheria-Ttetanus-Wooping cough+Haemophilus influenza type B+Polio
 Measles-Mumps-Rubella (German Measles)+Varicella (Chicken Pox) (MMRV)
 Pneumococcus bacteria (PCV)
 Hepatitis B
 Hepatitis A
 Rotavirus
Physical Examination:
Constitutional: No fever or weight loss. Martha mentions the baby is irritated at times
Eyes: Yes, seems to experiencing difficulty while sighting things kept at a distance
Ears, Nose, Mouth/Throat: Normal. No otorrhea or congestion
Cardiovascular: No history of cyanosis or heart murmur
Pulmonary: No history of coughing or increased breathing. However the mother reported
that the baby breaths heavily for some time and then stops breathing momentarily and then
starts breathing again. This only happens when the baby is sleeping.
GI: Mother reports that Noel passes gas after feeding and in the previous 24 hours had two
stools. Noel also vomited his last meal according to the mother.