INTRODUCTION OF THE PATIENT:

I. Name:- B/O Hasnura Bibi

II. Age:- 6 days
III. Sex:- Boy
IV. Diagnosis:- Hirschprunge disease
V. Date of Admission:- 4/03/2020
VI. Address:- 11, Dr Amal Roy Chandra road, Kolkata-700009

2. PRESENT MIDICAL HISTORY:

a. Chief Complaints:- i) Delayed passage of meconium followed by constipation

ii) Abdominal pain
iii) Recurrent vomiting
iv) Abdominal distention

b. Onset of Problem:- 2nd day of life

3 .PAST MEDICAL HISTORY:

a. Medical History:- Nothing significant

b. Surgical History:- Nothing significant

c. Any other Significant History:- Nothing significant

BIRTH HISTORY:

 Prenatal:-

 Age of Mother: 24 years

 Parity: 2nd
 Years since Marriage: 5 years
 Health Problems during pregnancy: Nothing significant
 History of Folifer Consumption: taken
 History of Addiction: Not present
 Antenatal Check-up: All the check-ups done at antenatal clinic
 Immunization:2 doses of injection T.T taken
  Intranatal:-
Type of delivery: Normal vaginal delivery
Any complication: Not raised

 Postnatal:-
 The baby was well, breastfeed after 1 hour of birth and urine normally. There was
delayed passage of meconium.
 No congenital malformation was present in the baby during 1st physical examination.
 No complication in mother raised ischia was normal, involution was normal, and breast
was not engorged.

DEVELOPMENTAL HISTORY:

Physical:-
 Weight:2.5 kgs
 Length:54 cm
 Head Circumference:38 cm
 Chest Circumference:40 cm

PERSONAL HISTORY:

 Behavior: Irritable
 Personal Hygiene: Maintained
 Bathing-: Regular bathing with Luke warm water at home.
 Sleeping: Normal
 Dietary History: Exclusive breastfeeding.

IMMUNIZATION HISTORY:

Immunization completed as per age.

ENVIRONMENTAL HISTORY:
 Type of House : Pacca
 No.of Room : Two
 Ventilation : Poor
 Light : Inadequate natural light
 Water Supply : Corporation supplied
 Pet : Not present
 Open Area Surrounding : Not present
FAMILY HISTORY:
 Type of family : Nuclear
 No.of family members : 4
 No.of sibling : 1
 Any disease in the family : Nothing significant

 Family genogram:-

Index
Male member

Female member

Death

Affected person
PHYSICAL EXAMINITION:

Date- 9/03/2020

GENERAL CONDITION:-

 Consciousness:Concious
 Posture: Flexed
 Gait: Normal
 Looks: Normal
 Color: Pink
 Activity: normal

Vital Signs:-
 Temperature: 99°C
 Heart Rate: 110 beats/minute
 Respiration: 36 breaths/minute

B.CENTRAL NERVOUS SYSTEM:

 Infant is conscious, alert, responding to stimuli appropriately.

 All the primary reflexes like sucking, swallowing, gag, blinking, Sneezing reflexes are
present.

RESPIRATORY SYSTEM:

 Chest movement: bilateral

 Respiratory pattern: Normal
 Air entry: Bilaterally equal
 Breath sound: Normal
 Cough: absent:

CARDIOVASCULAR SYSTEM:

 Normal
 Normotensive
 Heart sounds: S1 and S2 audible, no abnormal sound is present
 Neck veins distension: No
 Cyanosis:- not present
GASTROINSTIONAL SYSTEM:

 Mouth: clean
 Tongue: Clean
 Oral Ulcer: not present
 Peristalsis: normal
 Abdominal distension: not present
 Nausea/vomiting: not present
 NPM: Yes
 Bowel sound: audible
 Diarrhoea/Dysentry/Malena: nothing significant

GENITOURINARY SYSTEM:

 Ambiguous genitalia: Not present

 Testis: Both are present in scrotum

 Hernia: Not present

 Hydrocele: Not present

 Phimosis: Not present

 Site of urethral opening: normal

 Any other abnormality: Not detected

G. INTEGUMENTARY SYSTEM:

 Condition: surgical wound is present and healthy

 Cyanosis: not present
 Nails:
 Clubbing:- not present
 Capillary refilling: < 3 sec
 Edema: not present
 lcterus: not present
 Anaemia: not present
 Scalp: clean
MUSCULOSKELETAL SYSTEM:

 Anthropometric Measurement:-
o Weight: 2.6 kg
o Length: 54cm
o Head circumference:38 cm
o Chest circumference:40 cm
 Arms and legs are normal
 Hips normal
 Spine normal
 Muscle tone is good.