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The Diagnosis

Posted Sep 12 2008 3:28am

I had to translate the initial diagnostic report from our central hospital. For the record, here it is:


NAME: Kezia Lima Gascoigne

FATHER: Angus Robin Gascoigne

MOTHER: Fernanda Soares Lima

RESIDENCE:

DIAGNOSIS

Swollen spleen for investigation.

CLINICAL ANTECEDENTS

On Internment

The child was prescribed antibiotic treatment for impetigo on 02/05/06. Although this was effective, she developed a swollen spleen and lymph nodes and was admitted to the Paediatric Service on 05/05/06, where she was tested, diagnosed with severe anaemia, given a blood transfusion and prescribed more antibiotics.

On 10/05/06 she was allowed to return home and prescribed to take antibiotics (Clavox 250) for a further 7 days.

On 16/05/06 her mother noted facial edema, ambulatory difficulties, general pallidness and swollen lymph glands in the cervical region.

Physical Examination


a) Cervical region (dorsal): adenopatic, in the form of hard consistency packets.

b) Swollen spleen to 14 cm below the costal rib.

c) Liver: swollen and hydrated.

d) Other: facial edema

Treatment

After testing for haemoglobin with a level of 4 mg/dl, she was given a further blood transfusion (Group A+), intravenous crystalline penicillin and folic acid.


On 20 May we were on the plane.

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