The medical card summarizes the case of 11-month old Artyom Salyenko who was admitted to the hospital with acute respiratory disease, abdominal syndrome, fever, diarrhea, and vomiting. His physical exam was normal except for fever. Lab tests showed elevated white blood cell count. He was diagnosed with acute respiratory disease and given ORT, amoxicillin, paracetamol, and vitamins. After 7-10 days of treatment his condition improved.

1. SUMY STATE UNIVERSITY
MEDICAL INSTITUTE
PEDIATRICS DEPARTMENT
MEDICAL CARD
Name, surname of the patient: ARTYOM SALYENKO
Age of the patient: 11 months
Clinical diagnosis: ACUTE RESPIRATORY DISEASE
ACUTE ABDOMINAL SYNDROME
Basic diagnosis
Complication Non
Concomitant disease Non
Mark for the writing Curator PETER MABULA
of the case history ______________
The group 515, 5TH YEAR
Mark for the defense
of the case history ______________
Sumy
2010

2. GENERAL PATIENT’S INFORMATION
Name: ARTYOM
Surname: SALYENKO
Age: 11 Months
Home address: TOKAL SUMY
Date of admission to the hospital: 1 APRIL 2010
Pre-admission diagnosis: RESPIRATORY DISEASE, GIT SYNDROME
______________________________________________________________________
Patient’s department: INFECTIOUS (PEDIATRICS)
I. COMPLAINTS
Main: Fever, diarrhea and vomiting for 2 days.
II. ANAMNESIS OF THE DISEASE
The patient was apparently well until 2 days ago when he experienced an acute onset of fever which
was shoerly followed by diarrhea and vomiting on the very day.
His mother says he was previously given some food which she suspects to have caused the problem.
The previous treatment: He has a history of the same disease atleast every 3 months of which 3
months ago he suffered the same problem where he was treated and apparently was cured.
III. ANAMNESIS VITAE
For children till 3 years
The child was born from a health mother of which it was a SNVD at term and weighed 3.030kg.
During pregnancay there were no pregnancy associated complications though was born at home and
later was brought to the hospital for check up.
Apgar’s score was not immediately checked since it was a home delivery.
The child is breast fed and has received all necessary vaccinations.
Dynamics of head circumference: 46.5cm
Dynamics of chest circumference: 47.5cm
The psychomotor development of the child: normal and satisfactory
For all children irrespective of age
The child had the same disease 3 months ago and it has been recurrent.
Housing conditions of the child is satisfactory.
Character of nutrition before present disease (character of meal, schedule of feeding)
Normal and balanced diet.
Allergological history

3. Presence of allergy symptoms: NO
The intolerance of products: NO
The intolerance of medicament (drug): NO
No genetic illnesses
No allergic reactions
Epidemiological history
The child didn’t contact with patients who suffered with inflectional diseases last 3 weeks. The
symptoms of diarrhea were just 3 times a day and vomited once during last three days.
Genetical history
To make the pedigree of the patient, using common symbols:
Healthy woman
Healthy man
Proband
Sex unknown
Dead
Abortion
Medical abortion
Still-birth
Marriage
Consanguineous marriage
Repeated marriage
Unmarriage
Sibling
Monozygotic twins
Dizygotic twins

4. No known pregnancy
Sterility
Known heterozygous person
Carrier female
Pregnancy in progress
Affected person
Objective examination of the child
The patient’s general condition is moderately ill but satisfactorily responding to medication, The state
of consciousness is clear, The mental state is (not) adequate Position of the child in bed is active, The
patient is asthenic constitution. The child is of regular.
Anthropometrical measurements
Criterion In patient
Weight, kg 9.5kg
Height (stature), cm 75cm
Head 46.5cm
circumference, cm
Chest circumference, cm 47.5cm
The index by Erisman 10cm
Summary: The child’s anthropometric measures are within normal ranges.

5. The skin and mucous membranes
Colour of a skin - pink
lip-nose triangle normal and no cyanoses.
No skin rashes.
Surface of a skin is smooth. The elasticity of the skin is kept within normal.
Temperature of a skin is a bit febrile.
Sensitivity of the skin: temperature 38celsius,
Mucous membranes of a mouth reveals moist and smooth.
Gums: pink in colour and moist
Conjunctiva and sclera of eyes are a bit moist but no redness or discharge.
The subcutaneous fat is distributed evenly. The skin fold thickness is 2 cm on abdomen, 1.5cm under
the scapula, 1.5 cm on the shoulder, 2 cm on thigh. No oedema. The skin turgor is kept.
Lymphatic system
No palpable lymph nodes.
The tonsils. Not inflammed.
Muscular system
The development of muscles is satisfactory, well-developed and symmetrical. Muscular tone within
normal ranges. The range of motions is fully and no limitations
The strength of muscles moderately strong. No pain during palpation of the muscles.
Bone system
Head circumference is 46.5сm, (normal) The head is mesocephalic. Anterior fontanel
(presence,normal size and diamond shape, slight pulsation.
Posterior fontanel fused
Cardiovascular system
Inspection: During inspection of the chest no bulging, no visible pulsation seen, no cyanosis, no
odema, no jaundice.
Palpation: The apical or cardiac trust (beat) is located on 5th intercostal space midclavicular line, No
systolic or diastolic vibratory thrills palpable. Pulse (rate) is 134 beats per minute; rhythmic,
synchronic, full but swift, Blood pressure of upper extremities 85/53 mm Hg.
Border’s of hearts relative dullness

6. Border In patient Normal
Right Right parasternal line Corresponding with the patients
Upper 2nd rib parameters
Left 2cm outer of left mid-clavicular
line
transversa 8cm 6-9cm
l size
Border’s of hearts absolute dullness
Border In patient Normal
Right Left sterna line Corresponding to patients parameters
Upper 2nd intercostals space
Left Mid-clavicular line (outer)
transversa 2-3cm
l size
Auscultation: the heart sounds strong, rhythmical, 134 beats per min. S 1 is heard loudest at the apex of
the heart, S2 is heard loudest at the right 2nd intercostal parasternal.no accent.
No murmurs.
Respiratory system
No cyanosis of nasolabial triangle, per oral region, nails plates, acrocyanosis. Nasal breathing is free.
Voice is normal. No cough present. No dyspnoea, Chest has normosthenic,. The intercostals spaces are
normal.
Movements of the chest - symmetrical,
Type of breathing is combined (thoracic, abdominal). Dyspnea is absent. The respiration rate is 34 per
minute (normal, tachypnea, bradypnea). The breathing is regular,
Palpation: no pain on maxillary and frontal sinuses. Vocal fremitus is normal,
No Pleural friction rubs or crepitations.
In comparative percussion of the chest no abnormal or variational sounds heard.
The width of Crenig’s areas 4cm
Auscultation of the lungs: the breathing is vesicular and no
presence of rales, rhonchi or crepitations.
Digestive system
Inspection: The colour of mucous membranes of oral cavity is moist, no incrustation (coating), no
fissure or aphtha, colour of the tongue is pink, no inflammation of tonsils.

7. In vertical position the abdomen has normal shape, not distended, symmetrical abdominal
circumference and moves with breathing, no visible peristalsis, the umbilicus is centrally located, is
flatten. Also in horizontal position the abdomen has normal shape, moves with breathing, no distended
veins of the anterior abdominal wall “caput Medusa”.
In superficial palpation there is soft, the no present of tumour. Blumberg’ sign is negative; painless,
McBurney’s point.
Deep palpation according to Obraztsov-Strazhesko
Sigmoid colon is localized in LIF, cylindrical in shape with soft consistance and mobile. Caecum is
localized in RIF cylindrical shape, painfulness, movable,
Colon transverses is localized in epigastric region with cylindrical shape, Colon ascenders: is
localized in right part of the abdomen, cylindrical and normal consistance all painfulness.
Colon descendent is localized in the left side of the abdomen with cyllindrical shape, soft and mobile.
The liver not palpable, not tender,). Ortner’s symptom is negative, Ker’s symptom is negative,
Murphy’s symptom is negative, Mussi-Georgievsky’s symptom is negative. The spleen not palpable,
not tender.
Meyo-Robson’s symptom is negative. The pancreas not palpable
In auscultation intestinal peristalsis is not impaired.
Stool is 3 times per day- liquid, without an admixing.
Urinary system
Inspection: No oedema on legs, face, sacral part, or on the lower part of abdomen. The No change of
odour of urine though is said to be a bit concentrated.
Examination of sacral area, lower abdominal part. No change of color of the skin no edema.
Examination of the external sex organs: stage of development - no abnomarmality.
symmetric development of the scrotum Testis present in the scrotum; no inflammation of penis or
anomalies of penis development, phimosis, paraphimosis.
Kidneys not palpable in vertical or horizontal position. Pasternatsky’s symptom is negative on right
and on left side.
Urinary frequency 3 times a day, Daily urine flow 60ml per urination, proportion between day and
night diuresis2:1 Presence of uncontrolled urinations - no
Endocrine system
Examination: face expression - normal, no changes of anterior cervical surface. The level of
development subcutaneous fat is within normal parameters. Thyroid gland not palpable.
Nervous system
The consciousness is kept. The mental development corresponds to the age of child.).

8. Nn nystagmus. Pupils are equal in size; no mydriasis or miosis.
The light reflex is retained.
The coordination of movement is kept.
The pain sensitivity is kept. Tactile sensitivity is kept.
Newborn reflexes (the necessary underline): Sucking - is normal, hypoactive, hyperactive; Rooting -
is normal, hypoactive, hyperactive; Defence - is normal, hypoactive, hyperactive; Lip or trunk reflex -
is normal, hypoactive, hyperactive; Grasp - is normal, hypoactive, hyperactive; Babinski's - is normal,
hypoactive, hyperactive; Moro - is normal, hypoactive, hyperactive; Supporting - is normal,
hypoactive, hyperactive; Dance or step - is normal, hypoactive, hyperactive; Perez - is normal,
hypoactive, hyperactive; Crawling - is normal, hypoactive, hyperactive; Bauer's - is normal,
hypoactive, hyperactive; Galant - is normal, hypoactive, hyperactive. Upper Brudzinski’s reflex - is
normal, hypoactive, hyperactive; middle Brudzinski’s reflex - is normal, hypoactive, hyperactive; low
Brudzinski’s reflex - is normal, hypoactive, hyperactive. Tendon reflexes brisk, (equally marked on
both sides,
Psycho-motor development of the child
Gross motor development: Normal motor development
Fine motor development: Normal Motor functions
Sensory development : Normal sensory reflexes
Vocalization development:Normal
Socialization development: Child has no mental problems
The plan of examination of the patient
1) History
2) Physical examination
3) Lab tests
4)
Results of additional methods of examination
Rooting blood analysis
date Нb Eryth. CI Leuc Eos Bas juv. ban seg. lym mon ESR Blood clotting time
х1012 х109 d
1.4 117 3.7 o.9 5.1 2 3 21 72 1 3
Urinal examination according to Nechepurenco NOT DONE
Biochemical analysis of blood
date protein glucose Bilirubin Creatinin urea ALT AST Amylase
e

9. total total conjugated
Urinal examination according to Zymnitzky: NOT DONE
Portion 1 2 3 4 5 6 7 8
Quantities
of urine
specific
gravity
Analysis of feces on worm ova: Not done
Test on enterobiosis: Not done
Other methods of examination: Non
Systemic examination done accordingly to discover or exclude other pathologies
Clinical diagnosis:ACUTE RESPITORY DISEASE
Basic diagnosis:Awaiting Lab results
Complication: NON
Concomitant disease:ACUTE ABDOMINAL SYNDROME
Differential Diagnosis:
1) Enteral viral infection
2) Food poisoning (mild)
3) Acute Respiratory viral infection with secondary bacterial superinfection
4)
The temperature list
Data
B P T M E M E M E M E M E M E M E M E M E M E M E M E M E M E
P
Epicrisis
The patient: Artyom Salyenko
Age,11months,
Home address: Tokali Sumy
Undergoing treatment at Sumy pediatrics Hospital from April 1, 2010 with a preliminary diagnosis of
Acute Respiratory Disease and GIT Syndrome
The general state and data of objective examination of the patient on admission (shortly)

10. The patient was admitted with c/o acute respiratory disease accompanied with diarrhea and vomiting
plus high fever up to 38 celsius. The child is adynamic and weak. Has not been breastfeeding and
eating since the beginning of the disease. Diarrhea 2 times and vomiting once a day.
Prescribed treatment:
1) ORT 150ml/kg/1st 6hours then the same amount/day
2) Amoxycillin 100mg/kg qid for 7-10 days
3) Paracetamol 10mg/kg tid 3/7
4) Vitamins supprementations
Recommendations:
1. Normal diet
2. Regimen : Bed rest
Literature:
Nelson text book of Pediatrics
Case Hx by: Peter Mabula
5th Year
Group 515