pediatric сase history

4,247 views

Published on

0 Comments
3 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
4,247
On SlideShare
0
From Embeds
0
Number of Embeds
5
Actions
Shares
0
Downloads
116
Comments
0
Likes
3
Embeds 0
No embeds

No notes for slide

pediatric сase history

  1. 1. KHARKOV NATIONAL MEDICAL UNIVERSITY DEPARTMENT OF PEDIATRICS №2 STUDENT’S CASE HISTORY (SCH) Student (In Charge):_______________________ Group_________________________________ Faculty________________________________ Course (year)___________________________ Teacher________________________________ Date of giving the SCH for checking up ______________________________________ Mark__________________________________ Teachers Signature______________________ Date " _____" ____________20 KHARKOV
  2. 2. I. GENERAL INFORMATIONName________________________________________________________________________Age, date of birth_______________________________________________________________Address__________________________________________________________________________________________________________________________________________Date and time of admission_______________________________________________________By what medical establishment was directed to hospital _____________________________________________________________________________________________________________With what diagnosis_____________________________________________________________ ________________________________________________________________________Final diagnosis_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________II. COMPLAINTS (at time of admission)___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ III. ANAMNESIS MORBI (* - underline) Mode of onset and dates of onset of the symptoms. Health immediately before illness. Supposed andpossible causes, e.g. injury. Progress of the disease and appearance of fresh symptoms in their order as to onset.State of activity, appetite, bowels, sleep, changes in temperament, before and during the illness. Inquiry as tospecific physical signs and symptoms if information is not volunteered, e.g. wasting or loss of weight, withreference to weight-card if available, vomiting, pain, cough, convulsions, enuresis ._________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 2
  3. 3. IV. ANAMNESIS VITAE A. Previous Health Antenatal. Health of the mother during the pregnancy (medical supervision, diet, etc.). Rubella or otherinfections, medication, and stage of pregnancy at which it occurred. Vomiting. Toxemia. Antepartum hemorrhage.(Supplement from antenatal records in indicated cases, e.g. Wassermann reaction, Rhesus constitution).Employment during pregnancy.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Postnatal. Gestational age ______________Birth weight_____________. Duration of labor andmethod of delivery________________________________________________________.*Whether infant was born at home or in hospital (in the latter case, supplement from hospitalrecord if indicated, including resuscitation, oxygenadministration)______________________________________________________________________________________________________________________________________________. Neonatal. Apgar score_________. Whether skin color, cry and respiration were normal;*jaundice; feeding difficulties, rashes; twitching, flaccidity. Any other abnormalitiesnoted_______________. Transfusion or other treatment (confirm from hospitalrecord)_______________________________________________________________________. Later life. Exact details of feeding in early months; whether breast-fed_______, and if so, for howlong_________; type of formula feeding used____________________; whether vitaminadditives were given__________, and if so, the preparation’s amount andduration_______________________. Weaning transition to solid feeding: age and ease withwhich carried out______________________________. Appetite in infancy andsubsequently____________________________________. History of convulsions, skin rashes, diarrhea, infectious or other illnesses.____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Inquire specifically measles, rubella, pertussis, mumps, and chicken pox._______________________________________________________________________________________________________________________________________________________________________________________________________________________________________Immunization and tests_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________.Operations: ____________________________________________________________________Recent contact with infectious diseases, especially tuberculosis:_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 3
  4. 4. B. Development -Ages of head balance__________, sitting ___________and unsupportedwalking________, talking (words_______ and sentences_______), reading___________. -Ages at which gained control of bowel__________ and bladder_______ (a) during day,(b) at night. Any special difficulties in toilet training____________________________. -Whether child can eat ________and dress himself __________, and if so, how early hebegan to do so_________________________________________________________________. -School progress, e.g. average age of class and place in class; school report ifindicated________________________________________________________________.Special aptitudes. -Social adjustment with other children at home, at school ________________________. C. Family history. Parents’ age and whether any consanguinity exists. (In familial conditions, including genealogical tree,showing affected members, any consanguinity marriages, etc.). Health of close relatives (especially hereditary andcongential disorders, nervous and mental diseases). Mother _________________________________________________________________ Father ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ The children in their order, with details of age and health, and including death, stillbirth, and abortions. D. Social history Whether the mother is employed part-time or full-time, and if so, what care provided for children. Size ofhouse, situation, sanitation, ventilation, lighting, access to playground or open air. Details of family income ifrelevant._______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ E. Habits -Eating: appetite __________, food dislikes ___________________________________,feeding habits of child’s parents___________________________________________________. -Sleeping: hours______, disturbances, snoring, restlessness, dreaming, and nightmares(*). -Exercise and play________________________________________________________. K. Disturbances (*) Excessive bed wetting, masturbation, thumb sucking, nail biting, breath-holding, tempertantrums, tiecs, nervousness, undue thirst, other. Similar disturbances among members of thefamily. School problems (learning, perception). 4
  5. 5. V. PHYSICAL EXAMINATION (On examination)Temperature (t0) ____________________________________________________________pulse rate (Ps)_________ _____________________________________________________respiratory rate (RR)___________________________________________________________blood pressure (BP)___________________ _________________________________________weight__________________________________________________________________height___________________________________________________________________head circumference ________________________________________________________(The results of investigations must be compared with age standards). GENERAL CONDITION________________________________________________________________________ Degree of prostration: degree of cooperation________; state of comfort_______,nutrition_________________________, and consciousness______________; abnormalities;gait__________________, posture_________________, and coordination________________;estimate of intelligence___________________________________: reaction to parents,physician, and examination: nature of cry and its degree; facial expression_________________. SKIN Color ______________(cyanosis, jaundice, pallor, erythema), texture_________,eruptions______________________________________________________________________,hydration_________________,edema________________________________________________________________________,hemorrhagic manifestations____________________________________________________,scars ______________________, dilated vessels ___________________and direction of bloodflow, hemangiomas______________________, nevi________________, Mongolian (blue-black, coffee-like) spots ________________, pigmentation_____________________,turgor_____________________, elasticity__________________, and subcutaneousnodules_______________. Striae and wrinkling________________.Sensitivity______________, hair distribution______________________, character, anddesquamation. LYMPH NODES Location__________________________________, size________________,sensitivity_________________________, mobility_______________________,consistency_____________________________. (One should routinely attempt to palpate the suboccipital, preauricular, anterior cervical, posteriorcervical, submaxillary, sublingual, axillary, epitrochlear and inguinal lymph nodes). HEAD Size______________, shape______________________, circumference______________,asymmetry_______________, cephalohematoma___________, fossae__________________,craniotabes_______________, fontanel (size__________, tension____________,number_____________, abnormally late or early closed____________,suture_______________, dilated veins____________, scalp________________, hair-texture_________________, distribution_____________, parasites________________, etc.). FACE Symmetry ________________, paralysis__________________, the distance between anose and mouth______________, depth of the nasolabial folds________________, the bridge ofthe nose________________, a size of the mandible___________________,swellings_______________, hypertelorism____________, Chvostek’s sign_______________,tenderness over the sinuses_______________________________________________________. 5
  6. 6. EYES Photophobia________________, visual acuity________________, muscular controlnystagmus______________, Mongolian slant____________, Brushfieldspots__________________, epicanthic folds_________________, lacrimation______________,discharge___________, the lids____________, exophthalmos or enophthalmos, theconjunctivas__________________; papillary size_________, shape________________, andreaction to light and accommodation________________; medial (corneal opacities cataracts),fundus, visual fields (in older children) _________________________________________. NOSE Exterior________________, shape__________, mucosa_______________, patency,discharge________________, bleeding______________, pressure over the sinuses, flaring of thenostrils, the septum. THROAT The tonsils (size______________, inflammation______________,exudates___________, crypts_____________, inflammation of the anteriorpillars_____________), mucosa______________________, hypertrophic lymphoidtissue___________________, postnasal drip________________, epiglottis, voice (hoarseness,stridor, drunting, type of cry, speech).(underline) EARS The pinnas (position_____________, size___________), canals __________________,tympanic membranes (landmarks, mobility, perforation, inflammation, discharge), mastoidtenderness and swelling ______________________, hearing_________________________. NECK Position (torticollis, opisthotonos, inability to support the head, mobility), swelling thethyroid (size, contour, bruit, isthmus, nodules, tenderness), lymph nodes, veins, position of thetrachea, sternocleidomastoid muscle (swelling, shortening), webbing, edema, auscultation,movement, tonic neck reflex. THORAX Shape ________________and symmetry_____________, the veins, retractions andpulsations, heading, Harrison’s groove____________, flaring of the ribs_______________,pigeon breast, funnel shape, size and position of the nipples____________________, breasts___________________________, length of the sternum___________________. Intercostaland substernal retraction___________________, asymmetry________________, thescapulas__________________________, clavicles___________________________. EXTREMITIES A. General (*): deformity, hemiatrophy, bowlegs (common in infancy), knock-knees(common after two years); paralysis, edema, coldness, posture, gait, stance, asymmetry. B. Joints (*): swelling, redness, pain, limitation of motion, tenderness, rheumaticnodules, carrying angle of the elbows, tibia torsion. C. Hands and feet (*): extra digits, clubbing, simian lines, curvature of the little finger,deformity of the nails, splinter hemorrhages, flat during the first two years), abnormalities of thefeet, the width of the thumbs and big toes, syndactily, length of various segments, dimpling ofthe dorsa, temperature. D. Peripheral vessels (*): presence, absence or diminution of arterial pulses. 6
  7. 7. SPINE AND BACK Posture________________, curvatures____________________,rigidity_________________, a webbed neck__________, spina bifida, pilonidal dimple or cyst,tufts of hair, mobility, Mongolian spots, and tenderness over the spine, pelvis, and kidneys. LUNGSVoice sound _________________Rate of respiration ______________Type of breathing______________________,Dyspnea______________________________________________________________________Vocal fremitus__________________________________________________________________Comparative percussion__________________________________________________________ Auscultation: breathing________________________________________________________râles ___________________________________________________________________,crepitation___________________________, wheezing_________________________________. CARDIOVASCULAR SYSTEM Inspection and palpation of the heart areaApex beat_____________________________________________________________________,cardiac humpback________________, murmurs______________________________, etc.)._____________________________________________________________________________ Percussion: border of the heart dullness (relative). Border In child Normally Right Upper Left Auscultation:Heart sounds_________________________________________Rhythm______________________________________________.Murmurs (location, position in cycle, intensity, pitch, effects of change of position,transmission, effect of physical exercises)_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________. ABDOMEN Size and contour _________________________, visible peristalsis__________,respiratory movement_________________________________, the veins (distention, directionof flow)____________________________, umbilicus _____________,hernia_______________________, musculature_____________, tenderness andrigidity_________________, palpable organs or masses (size, shape, position, mobility), fluidwave, reflexes, bowel sounds. LIVER Size (palpation________________________, percussion). Tenderness ______________.Surface_________________________. Inferior margin ______________. SPLEEN Palpable or not. Size___________, surface___________, tenderness________________. 7
  8. 8. UROGENITAL SYSTEM Urination______________________. Frequency________________,painfulness_______________, retention of urine____________________________.Pasternatsky’s sign ____________________________.Genitalia _________________________. Abnormal development. RECTUM AND ANUS Irritation_________, fissures____________, prolapse___________, anal atresia (innewborns). STOOL________________________________________________________________ NERVOUS SYSTEM General behavior________________________, level ofconsciousness______________________, intelligence___________________________,emotional status______________________, memory orientation______________________;illusion_________________________; ability to understand and tocommunicate_________________, speech______________________, ability towrite________________________________, performance of skilled motor acts_____________. Vegetative reactions. Dermography ____________________. Reflexes:Babinski’s___________________, Brudzinski’s________________;meningeal______________. Organs of sense. Sense of smell___________, sight___________, taste____________,touch________________________, hearing_____________________. VI. PROVISIONAL DIAGNOSIS (Diagnosis based on the facts of the Case History and Physical Examination)._____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 8
  9. 9. _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 9
  10. 10. VII. PLAN OF CLINICAL AND LABORATORY EXAMINATIONS (INVESTIGATIONS)_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ VIII. LABORATORY FINDINGS (Data and interpretation) 10
  11. 11. 11
  12. 12. IX. CURSUS MORBI (DIARY)Date Results of examinations of the patient Prescriptionst0 – DietPs –RR – RegimenBP – Drugs 12
  13. 13. X. DIFFERENTIAL DIAGNOSIS (2-4 diseases) 13
  14. 14. XI. FINAL DIAGNOSIS (TO GROUND) 14
  15. 15. XII. TREATMENT AND ITS GROUND (FOR THE DISEASE IN GENERAL ANDFOR THE PRESENT ONE IN PARTICULAR)RegimenDietDrugs with prescriptions 15
  16. 16. XIII. LITERATURE DATA ON THE PRESENT DISEASE (etiology, pathogenesis,clinical manifestations, classification, treatment, and prevention in general and concerning thepresent patient). 16
  17. 17. XIV. EPICRISIS (summary) 17
  18. 18. STUDENT’S CASE HISTORY (COMMENTS) The Student’s Case History (SCH) is the part of the curriculum designated for out-of-class work. It means that after primary examination and supervision of a patient in dynamics thestudent has to write the SCH according to the scheme proposed by the Department. This scheme includes the basic elements of doctor’s diagnostic and curative actionsduring his professional activities: history taking, examination, diagnosis, differential diagnosis,treatment, prevention of disease, analyses of effectiveness, prognosis, keeping medicaldocuments, etc. For a fourth year student the task is to produce these actions in a written form. Thus itwould be possible to objectively evaluate the student’s level of clinical training and theoreticalknowledge. The student has to answer all the questions of the Scheme. If there is no properinformation for some questions the student would answer adequately naming all the points. Forexample “Operation – there were no operations”; “Accidents and injuries - there were no ones”“Gastrointestinal tract – there were no vomiting, diarrhea, constipation, etc.” Working with the SCH under the guidance of his teacher the student receives from himthe recommendations about the list of the diseases to be considered during differential diagnosisand consulting the students in the process of taking history, examination, prescribing thetreatment, making the SCH. In section “Present Illness” it is necessary to describe the course of the patient’s diseasefrom its onset till the initial examination by the student. For Sec. “Provisional Diagnosis” the student has to name all the symptoms, which wouldbe the ground for diagnosis, complaints and results of the physical examination. For VII Sec.” Plan…” the student has to name all the investigations which are necessaryfor confirmation of the provisional diagnosis. For IX Sec. “ Diary” it is necessary to give quite brief information about the patient’sstate on the day of the examination. Obligatory data: Complaints. General Condition (mild,moderate, severe, unconsciousness, comatose, critical, etc.). Temperature. Pulse. Respirationrate. Skin. Throat. Breathing. Heart (Sounds). Abdomen. Liver. Spleen. Stool. Urination. If there are any disturbances in the organs and systems the details of them have to bedescribed. The description of the status depends on the age of the patient. In infants more attentionhas to be paid to peculiarities of feeding, weight, and stool. The structure of the status changes according to the nature of the disease. In patients withneurological pathology, neurological status has to be dynamically described; for gastrointestinaldisorders stool and defecation are substantial, and so on. The instructions concerning these aspects are to be obtained from the teacher. In X Sec. “Differential diagnosis” the student first reveals the patient’s symptoms, whichare common both the supposed disease and for others. Then for every considered disease thestudent proves why the latter is denied. XI. “Final Diagnosis” means the summary in diagnosing. 18

×