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Medical Report Composition

Chief Complaints

There was yellowing of the eyes, hands and feet for one day and the child was irritable and unable to suck for one day.

History of presenting illness

The patient is a referral from London Medical Hospital. The mother reports that the patient was well until 4 days prior to his admission when his mother noticed yellowing of the eyes. The yellowing of the eyes was sudden in onset, progressed from the head downwards to the hands and later to the feet, it was associated with dark stools but normal urine color, it was throughout the whole day and did not have any relieving or exacerbating factors. On that day, the child had breastfed twice: in the morning and at night. The frequency of breastfeeding had reduced because the child used to breastfeed almost the whole day. The mother did not report skin wounds, pustules, rashes, pruritus, cough, vomiting, abdominal swelling diarrhea, convulsions or loss of consciousness. One day later, the mother decided to take the child to London Medical Hospital where she was told that the child had a fever of 39 degrees Celsius, a blood sample was taken and later on, admitted. The child was placed on a phototherapy machine for one day. The child was not getting well and they were referred to Dublin Hospital. At Dublin hospital, IV fluids were administered and he was placed on a phototherapy machine.

Surgical History

The child has not undergone any surgeries or blood transfusions.

Past Medical History

This is the patient’s index admission. The child does not suffer from any congenital disease or chronic illness such as diabetes or hypertension. The child does not have any known drug allergies.

Family History

The mother is 26 years and the father is 28 years old. They both live together. This is the first child. The father does casual jobs and the mother is the housewife. There is no family history of chronic illnesses in the family.


The patient is not taking any medications.

Physical Exam

On examination, James is asleep, in good general condition, lying inside a phototherapy box, was not in any signs of respiratory distress and was of good nutritional status.
Jaundice is present, no pallor, no cyanosis, no lymphadenopathy, no finger or toe clubbing and no edema.
Vital signs
Respiratory rate- 48 Pulse rate- 76, Temperature- 37.2, Blood pressure-124/82
Systemic Exam
Skin- moderate Yellowing of the skin of the hands and feet.
No wounds, rashes or septic pustules.
Respiratory system-Normal chest wall
No tracheal deviation
Equal chest expansion
Apex beat at the fifth left intercostals space.
Normal resonance
Vesicular breathing
No crackles or wheeze
Cardiovascular system-No visible pulsations
Apex beat at the fifth left intercostals
S1 and S2 heard
No crepitations
Gastrointestinal system-No abdominal swelling
No edema
Central Nervous system- -ve kernings sign
Diagnostic tests
The medical doctor should request for a complete blood count, urea/electrolytes and creatinine levels, random blood sugar levels and bilirubin levels (National Collaborating Centre for Women’s and Children’s Health, 2010).
Treatment plan
Medical care for this patient will include: phototherapy, nasogastric tube feeds or breast milk if they start breastfeeding, fluid maintenance, monitoring of random blood sugar levels and keeping the child warm if they are not inside the phototherapy box.( Ullah, S., Rhaman, K., & Hedayati, M. ,2016)


Ullah, S., Rhaman, K., & Hedayati, M. (2016, April). Hyperbilirubinemia in Neonates: Types, Causes, Clinical Examinations, Preventive Measures and Treatments: A Narrative Review Article. Retrieved from
National Collaborating Centre for Women’s and Children’s Health (UK). (2010, May). Neonatal Jaundice – NCBI Bookshelf. Retrieved from



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