1 МІНІСТЕРСТВО ОХОРОНИ ЗДОРОВ'Я УКРАЇНИ Харківський національний медичний університет EDUCATIONAL CASE HISTORY ON PEDIATRICS (4 th year – Pediatrics, 5 th year – Diseases of blood system in children) Practical policies for students НАВЧАЛЬНА ІСТОРІЯ ХВОРОБИ З ПЕДІАТРІЇ (4-й курс – Педіатрія, 5-й курс – Хвороби системи крові у дітей) Робочий зошит для студентів Затверджено Вченою радою ХНМУ. Протокол № 7 від 24.06.2021. Харків ХНМУ 2021 2 Educational case history on Pediatrics (4 th year – Pediatrics, 5 th year – Diseases of blood system in children) : practical policies for students / comp. N.I.Makieieva, K.K.Iarova, N.P.Alieksieieva et al. – Kharkiv: KhNMU, 2021. – 36 p. Compilers N. I. Makieieva K. K. Iarova N. P. Alieksieieva I. M. Piddubna O. O. Afanasieva Навчальна історія хвороби з педіатрії (4 курс – Педіатрія, 5 курс – Хвороби системи крові у дітей) : робочий зошит для студентів / упоряд. Н. І. Макєєва, К. К. Ярова, Н. П. Алєксєєва та ін. – Харків : ХНМУ, 2021. ‒ 36 с. Упорядники Н. І. Макєєва К. К.Ярова Н. П.Алєксєєва І. М.Піддубна О. О.Афанасьєва 3 INTRODUCTION Writing a medical history is a mandatory part of a student's out-of-class work in the study of clinical disciplines, in particular, "Pediatrics". The purpose of writing a medical history in clinical departments is not only to improve the skills of collecting complaints and anamnesis, to conduct a physical examination of the patient, but also to acquire skills in clinical understanding of the information received (rationale of preliminary and final diagnoses, drawing up an examination plan, making a differential diagnosis, prescribing therapy). In addition, the implementation of this type of work in writing (writing a medical history) according to a scheme that includes the main elements of diagnostic and therapeutic actions of a doctor in his professional activity, contributes to the formation of a concise and reasonable presentation of information using medical terminology. The scheme of case history includes the basic elements of doctor’s diagnostic and curative actions during his professional activities: history taking, examination, diagnosis, differential diagnosis, treatment, prevention of disease, analyses of effectiveness, prognosis, keeping medical documents, etc. The scheme of the case history for 4-year-students – “Pediatrics” (Supplement 1) and 5-year-students – “Diseases of blood system in children” (Supplement 2), offered by the Department of Pediatrics No. 2 of KhNMU, includes 12 sections that must be completed after the initial examination and the results of additional methods of examining the patient by the student. Until the moment the medical history is submitted for verification, the student can get advice from the teacher on issues that cause difficulties (interpretation of data, conducting a differential diagnosis, etc.). Checking the medical history allows you to objectively assess the level of clinical training and theoretical knowledge of the student. GENERAL RECOMMENDATIONS OF THE DEPARTMENT OF PEDIATRICS № 2 REGARDING WRITING THE CASE HISTORY Writing a medical history is a difficult and time-consuming process, so do not hesitate this work up to the last night before the deadline. After physical examination of the patient, “decipher” (“spell out”) your notes and, if any questions arise, solve them promptly (help from a friend, teacher, etc.). Before writing a medical history directly, read the literature on the disease that is diagnosed in the patient. RECOMMENDATIONS FOR WRITING SOME SECTIONS OF THE CASE HISTORY Section "ANAMNESIS MORBI". Complaints are presented considering their diagnostic significance for the diagnosis. When writing an anamnesis of a present disease, it is necessary to concisely describe the course of the patient's disease from its onset to the initial examination by the student. Section "ANAMNESIS VITAE". It is necessary to collect as much as possible an anamnesis of the patient's life during supervision. If the child cannot answer any questions, do not hesitate to check the patient's life history with the teacher. Do not forget that a well-collected history is key to the success of the final diagnosis. Section "PHYSICAL EXAMINATION". The OBJECTIVE data should not include your interpretation of the physical findings obtained (e.g., "allergic rash", "lymph nodes are not enlarged", "submandibular lymph nodes the size of a pea", etc.). It is necessary to name the elements of the rash (papular, petechial, etc.), to indicate the dimensions in centimeters or millimeters, to use generally accepted topographic landmarks, etc. Section "PROVISIONAL DIAGNOSIS (substantiation of the provisional diagnosis)". Based on the data obtained (characteristic complaints, anamnesis of the disease, identified syndromes), the main preliminary DIAGNOSIS is established and substantiated in accordance with the accepted classifications. In the presence of concomitant pathology, it is necessary to indicate it (justification is not required). In the section "Plan of examination" the student must name all the studies that are necessary to confirm the preliminary diagnosis. You should not include in the plan of examination those studies that are not diagnostically significant. 4 In the section "Test results", after indicating the actual results, it is imperative to give them an interpretation using medical terminology (for example, "neutrophilic leukocytosis", "proteinuria", "hyperkalemia", etc.). In addition, it is necessary to try to explain the reason for the origin of the identified changes. In the "Diary" section it is necessary to provide brief information about the patient's condition on the day of the examination. Mandatory data: Complaints. General condition (satisfactory, moderate, severe, etc.). Temperature. Pulse. Breathing rate. Skin. Mucous membranes. Respiratory system. Heart (tones, noises). Stomach. Liver. Spleen. Chair. Urination. If there are any violations in organs and systems, it is necessary to describe them in detail. The description of the status depends on the age of the patient. In infants, more attention should be paid to feeding habits, weight, and stool. The structure of the status changes depending on the nature of the disease. Instructions regarding these aspects can be obtained from the teacher. The “DIFFERENTIAL DIAGNOSIS” section is usually the most difficult to write a case history. The differential diagnosis is carried out in a narrative form (rewriting tables is not allowed!!!). First, the patient's symptoms are indicated, which are common both for the alleged disease and for others with which the differential diagnosis is made. Then, for each disease under consideration, it is necessary to prove why it is excluded. Section "DIAGNOSIS AND ITS RATIONALE" means the rationale for the final diagnosis using complaints, anamnesis, objective data, data from additional research methods, dynamics of observation, and the differential diagnosis carried out. Section "TREATMENT AND ITS RATIONALE (with the obligatory prescription of drugs prescribed for the supervised patient)". Each point of therapy must be substantiated (do not forget diet and regimen!). Therapy (etiotropic, pathogenetic, symptomatic) should be necessary and sufficient. Avoid polypharmacy (simultaneous administration (often unjustified) to a patient of several drugs)!!! Writing prescriptions for prescribed drugs is MANDATORY with the indication of doses calculated for the supervised child, considering body weight or surface area. The section "EPICRISIS" or "a summary of the previous series", after reading which you can get a complete picture of the patient, the competence of the diagnosis, the dynamics of the child's condition on the background of the prescribed treatment, recommendations for further treatment and observation. The epicrisis should be concise, but sufficient to obtain complete information about the patient, recommendations - specific and detailed. REFERENCES 1. Bates' Guide to Physical Examination and History Taking 12th edition. Edited by Lynn Bicley. – Lippincott Williams &Wilkins. – 2016. – 1072 p 2. Nelson textbook 20 th Edition by Robert M. Kliegman, MD, Richard E. Behrman, MD, Hal B. Jenson, MD and Bonita F. Stanton, MD. Видавництво: SAUNDERS 3. The Harriet Lane Handbook, 21 st edition. International edition, 2018. – 1255 p. 5 Supplement 1 KHARKIV NATIONAL MEDICAL UNIVERSITY DEPARTMENT OF PEDIATRICS №2 STUDENT’S CASE HISTORY (SCH) (the 4 th year studying) Student (In Charge):_______________________ Group __________________________________ Faculty _________________________________ Course (year) ____________________________ Teacher_________________________________ Date of giving the SCH for checking up _______________________________________ Mark __________________________________ Teacher's Signature_______________________ Date " _____" ____________ 20 KHARKIV 6 I. GENERAL INFORMATION Name ___________________________________________________________________________ Age, date of birth _________________________________________________________________ Address _________________________________________________________________________ ________________________________________________________________________________ Date and time of admission _________________________________________________________ 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 and possible 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 to specific physical signs and symptoms if information is not volunteered, e.g. wasting or loss of weight, with reference to weight-card if available, vomiting, pain, cough, convulsions, enuresis. ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 7 IV. ANAMNESIS VITAE A. Previous Health Antenatal. Health of the mother during the pregnancy (medical supervision, diet, etc.). Rubella or other infections, 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 _____________. *Whether infant was born at home or in hospital (in the latter case, supplement from hospital record if indicated, including resuscitation, oxygen administration) _________________________________________________ ________________________________________________________________________________ Neonatal. Apgar score _________. *Whether skin color, cry and respiration were normal; jaundice; feeding difficulties, rashes; twitching, flaccidity. Any other abnormalities noted _______________. Transfusion or other treatment (confirm from hospital record) _____________________________. Later life. Exact details of feeding in early months; whether breast-fed _______________________, and if so, for how long __________________; type of formula feeding used ____________________; whether vitamin additives were given __________________, and if so, the preparation’s amount and duration __________________________. Weaning transition to solid feeding: age and ease with which carried out ______________________________. Appetite in infancy and subsequently ________________________________________________________________________________ ________________________________________________________________________________ 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: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 8 B. Development ‒ Ages of head balance __________, sitting ___________ and unsupported walking ________, 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 he began to do so ___________________________________________________________________________. ‒ School progress, e.g. average age of class and place in class; school report if indicated ________________________________________________________________________________ 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 and congenital 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 of house, situation, sanitation, ventilation, lighting, access to playground or open air. Details of family income if relevant. ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 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, temper tantrums, tics, nervousness, undue thirst, other. Similar disturbances among members of the family. School problems (learning, perception). 9 V. PHYSICAL EXAMINATION (On examination) Temperature (t°) __________________________________________________________________ pulse rate (Ps) ____________________________________________________________________ respiratory rate (RR) _______________________________________________________________ blood pressure (BP) _______________________________________________________________ weight __________________________________________________________________________ height __________________________________________________________________________ (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 ___________________________________________________________________, hemangiomas ____________________________________________________________________, nevi ___________________________________________________________________________, Mongolian (blue-black, coffee-like) spots _____________________________________________, pigmentation ____________________________________________________________________, turgor __________________________________________________________________________, elasticity ________________________________________________________________________, and subcutaneous nodules __________________________________________________________. Striae and wrinkling ______________________________________________________________. Sensitivity ______________________________________________________________________, hair distribution __________________________________________________________________. LYMPH NODES Location ________________________________________________________________________, size ____________________________________________________________________________, sensitivity _______________________________________________________________________, mobility ________________________________________________________________________, consistency _____________________________________________________________________. (One should routinely attempt to palpate the suboccipital, preauricular, anterior cervical, posterior cervical, submaxillary, sublingual, axillary, epitrochlear and inguinal lymph nodes). 10 HEAD Size ________________, shape ______________________, circumference __________________, asymmetry ________________, cephalohematoma _______________, fossae ________________, craniotabes _______________, fontanel (size ______________, tension ____________, abnormally late or early closed _____________________, suture ______________________, dilated veins ________________, scalp ______________, hair-texture _________________, distribution ________________________________________, parasites ________________, etc.). FACE Symmetry _______________________________, paralysis _______________________________, the distance between a nose and mouth ________________________________________________, depth of the nasolabial folds ___________________, the bridge of the nose __________________, a size of the mandible ______________________, swellings ____________________, hypertelorism _________________________, Chvostek’s sign ____________________________, tenderness over the sinuses _________________________________________________________. EYES Photophobia __________________________, visual acuity _______________________________, muscular control nystagmus ____________________, Mongolian slant ______________________, Brushfield spots ________________________, epicanthic folds ____________________________, lacrimation ___________________, discharge _________________, the lids _________________, exophthalmos or enophthalmos, the conjunctivas ________________________________________; papillary size _____________________, shape __________________________, and reaction 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 the nostrils, the septum. THROAT The tonsils (size ________________, inflammation ________________, exudates _____________, crypts ________________________, inflammation of the anterior pillars __________________), mucosa ______________________, hypertrophic lymphoid tissue _____________________, postnasal drip ________________, epiglottis, *voice (hoarseness, stridor, grunting, type of cry, speech).(* ‒ underline) *EARS The pinnas (position ____________________, size _____________), canals __________________, tympanic membranes (landmarks, mobility, perforation, inflammation, discharge), mastoid tenderness and swelling _________________________, hearing ___________________________. *NECK Position (torticollis, opisthotonos, inability to support the head, mobility), swelling the thyroid (size __________________, contour ___________________, tenderness ____________________). THORAX Shape ________________ and symmetry _____________, the veins, retractions and pulsations, Harrison’s groove ________________________________________________________________, flaring of the ribs _________________________________________________________________, pigeon chest, funnel shape, size and position of the nipples ________________________________, breasts ________________________________________________________________________. Intercostal and substernal retraction ______________________, asymmetry __________________, the scapulas _____________________________, clavicles ________________________________. 11 EXTREMITIES A. General (*): deformity, hemiatrophy, bowlegs, knock-knees; paralysis, edema, coldness, posture, gait, stance, asymmetry. B. Joints (*): swelling, redness, pain, limitation of motion, tenderness, rheumatic nodules, 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 the feet, the width of the thumbs and big toes, syndactyly, length of various segments, dimpling of the dorsa, temperature. D. Peripheral vessels (*): presence, absence, or diminution of arterial pulses. 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 _________________________________________________________________________. RESPIRATORY SYSTEM Voice 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 area Apex beat _______________________________________________________________________, cardiac humpback _____________________, murmurs ______________________________, etc.). ________________________________________________________________________________ Percussion: border of the heart dullness (relative). Border In child Normally Right Upper Left Auscultation: Heart rate ________________ BP ___________ Heart sounds _____________________________________________________________________ Rhythm _________________________________________________________________________ Murmurs (location, position in cycle, intensity, pitch, effects of change of position, transmission, effect of physical exercises) _________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 12 ABDOMEN Size and contour _________________________, visible peristalsis _________________________, respiratory movement _____________________________________________________________, the veins (distention, direction of flow) _______________________________________________, umbilicus _________________, hernia _______________________, musculature _____________, tenderness and rigidity _____________________________________________________________, palpable organs or masses (size _______, shape ______, position ________, mobility __________), fluid wave ______________________________________________________________________, reflexes _________________________________________________________________________ _______________________________________________________________________________, bowel sounds ____________________________________________________________________. LIVER Size (palpation __________________________, percussion ______________________________). Tenderness ____________________________. Surface _______________________________. Inferior margin ________________________. SPLEEN Palpable or not _______________________. Size ___________, surface ________________________, tenderness ________________. UROGENITAL SYSTEM Urination __________________________________. Frequency __________________________________, painfulness __________________________, retention of urine ___________________________. Pasternatsky’s sign __________________________. Genitalia __________________________________. Abnormal development. RECTUM AND ANUS Irritation _________, fissures ____________, prolapse e___________, anal atresia (in newborns). STOOL ________________________________________________________________________ NERVOUS SYSTEM General behavior ________________________, level of consciousness ______________________, intelligence ___________________________, emotional status _________________________, memory orientation ______________________; illusion _________________________________; ability to understand and to communicate ______________________________________________, speech ______________________________, ability to write __________________________, performance of skilled motor acts ____________________________________________________. Vegetative reactions. Dermography __________________________________________________. Reflexes: Babinski’s ______________________________________________________________, Brudzinski’s _____________________; meningeal ______________________________________. Organs of sense. Sense of smell __________________________, sight ______________________, taste ______________________________________, touch _______________________________, hearing ____________________________________. 13 VI. PROVISIONAL DIAGNOSIS (TO GROUND) (Diagnosis based on the facts of the Case History and Physical Examination). ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 14 VII. PLAN OF CLINICAL AND LABORATORY EXAMINATIONS (INVESTIGATIONS) ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ VIII. TEST RESULTS (Data and interpretation) Blood analysis Date Hb RBC CI Reticulocytes Ht Platelets WBC Stab neutrophils Segmented neutrophils Eosinophils Basophiles Lymphocytes Monocytes ESR Conclusion:______________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 15 Urine analysis Volume Colour pH Specific gravity Protein Glucose WBC RBC Casts - hyaline - granular - RBC’ - WBC’ - other Epithelium Mucous Bacteria Conclusion:______________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Other investigations: 16 17 IX. CURSUS MORBI (DIARY) Date Results of physical examination of the patient Prescriptions t ° – Ps – RR – BP – Diet Regimen Drugs 18 X. DIFFERENTIAL DIAGNOSIS (2‒4 diseases) 19 XI. FINAL DIAGNOSIS (TO GROUND) 20 XII. TREATMENT AND ITS GROUND (FOR THE DISEASE IN GENERAL AND FOR THE PRESENT ONE IN PARTICULAR) Regimen Diet Drugs with prescriptions 21 XIII. LITERATURE DATA ON THE PRESENT DISEASE (etiology, pathogenesis, clinical manifestations, classification, treatment, and prevention in general and concerning the present patient). 22 XIV. SUMMARY (Lat. Epicrisis) 23 Supplement 2 KHARKIV NATIONAL MEDICAL UNIVERSITY DEPARTMENT OF PEDIATRICS №2 STUDENT’S CASE HISTORY (SCH) (the 5 th year studying) Student (In Charge): _______________________ Group __________________________________ Faculty _________________________________ Course (year) ____________________________ Teacher ________________________________ Date of giving the SCH for checking up _______________________________________ Mark __________________________________ Teacher's Signature_______________________ Date "_____" ___________________ 20 _____ KHARKIV 24 I. GENERAL INFORMATION Name ___________________________________________________________________________ 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 and possible 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 to specific physical signs and symptoms if information is not volunteered, e.g. wasting or loss of weight, with reference to weight-card if available, vomiting, pain, cough, convulsions, enuresis. ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 25 IV. ANAMNESIS VITAE A. Previous Health Antenatal. Health of the mother during the pregnancy (medical supervision, diet, etc.). Rubella or other infections, 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 and method of delivery ______________________________________________. *Whether infant was born at home or in hospital (in the latter case, supplement from hospital record if indicated, including resuscitation, oxygen administration) _______________________________. Neonatal. Apgar score ____________________________________________. Whether skin color, cry and respiration were normal; *jaundice; feeding difficulties, rashes; twitching, flaccidity. Any other abnormalities noted __________________________________________________________. Transfusion or other treatment (confirm from hospital record) ______________________________ _______________________________________________________________________________. Later life. Exact details of feeding in early months; whether breast-fed _______________________________, and if so, for how long ________________; type of formula feeding used ____________________; whether vitamin additives were given _________________________________________________, and if so, the preparation’s amount and duration ________________________________________. Weaning transition to solid feeding: age and ease with which carried out _____________________. Appetite in infancy and subsequently _________________________________________________. 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: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 26 B. Development ‒ Ages of head balance __________, sitting ___________and unsupported walking ________, 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 he began to do so _______________________________________________. ‒ School progress, e.g. average age of class and place in class; school report if indicated _______________________________________________________________________________. 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 and congential 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 of house, situation, sanitation, ventilation, lighting, access to playground or open air. Details of family income if relevant. ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 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, temper tantrums, tics, nervousness, undue thirst, other. Similar disturbances among members of the family. School problems (learning, perception). 27 V. PHYSICAL EXAMINATION (On examination) Temperature (t ° ) __________________________________________________________________ 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 _________________, rashes, localization and their character: hemorrhage, ecchymosis, petechial, maculopapular elements, etc. ____________________________________________________________________ _______________________________________________________________________________, hydration _________________, edema ______________________________________________, hemorrhagic manifestations ________________________________________________________, scars ____________________, dilated vessels ___________________and direction of blood flow, hemangiomas ______________________, nevi________________, Mongolian (blue-black, coffee- like) spots _________________________________, pigmentation _________________________, turgor __________________________________, elasticity _______________________________, hair distribution___________________________________________, character, and desquamation. LYMPH NODES Location __________________________________, size _________________________________, sensitivity __________________________, mobility ____________________________________, consistency______________________________________________________________________. (One should routinely attempt to palpate the suboccipital, preauricular, anterior cervical, posterior cervical, submaxillary, sublingual, axillary, epitrochlear and inguinal lymph nodes). BONE SYSTEM (visible deformation of bones, spine, limb shortening, the shape of the skull) ________________________________________________________________________________ ________________________________________________________________________________ JOINTS (shape, tenderness, her character, swelling, hyperthermia), movement in the joints ________________________________________________________________________________ ________________________________________________________________________________ LUNGS Voice sound _________________ Rate of respiration ________________________ Type of breathing _________________________, Dyspnea ________________________________________________________________________ Vocal fremitus ___________________________________________________________________ Comparative percussion ____________________________________________________________ Auscultation: breathing _________________________________________________________ râles ___________________________________________________________________________, crepitation ___________________________, wheezing __________________________________. 28 CARDIOVASCULAR SYSTEM Inspection and palpation of the heart area Apex beat _____________________________________________________________________, cardiac humpback _____________________, murmurs ______________________________, etc.). ________________________________________________________________________________ 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, direction of flow) __________________________________, umbilicus _______________________________, hernia _________________________________, musculature ______________________________, tenderness and rigidity _________________, palpable organs or masses (size, shape, position, mobility), fluid wave, reflexes, bowel sounds. LIVER Size (palpation ________________________, percussion). Tenderness ______________________. Surface ______________________________. Inferior margin _____________________________. SPLEEN Palpable or not. Size ____________________, surface ___________________________________, tenderness ________________. UROGENITAL SYSTEM Urination ___________________________. Frequency _________________________________, painfulness __________________________, retention of urine ____________________________. Pasternatsky’s sign _______________________________________________________________. Genitalia _________________________. Abnormal development. STOOL_________________________________________________________________________ NERVOUS SYSTEM General behavior _______________________, level of consciousness______________________, intelligence ___________________________, emotional status ____________________________, memory orientation _____________________; illusion __________________________________; ability to understand and to communicate ______________________________________________, speech ____________________________, ability to write ________________________________, performance of skilled motor acts ____________________________________________________. Vegetative reactions. Dermography __________________________________________________. Reflexes: Babinski’s ______________________, Brudzinski’s ____________________________; meningeal ______________________________________________________________________. Organs of sense. Sense of smell __________________________, sight ______________________, taste __________________________________, touch ________________________________, hearing _________________________________________________________________________. 29 VI. PROVISIONAL DIAGNOSIS (TO GROUND) (Diagnosis based on the facts of the Case History and Physical Examination). ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ 30 VII. PLAN OF CLINICAL AND LABORATORY EXAMINATIONS (INVESTIGATIONS) ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ VIII. TEST RESULTS (Data and interpretation) 31 32 IX. DIFFERENTIAL DIAGNOSIS (2‒4 diseases) 33 X. FINAL DIAGNOSIS (TO GROUND) 34 XI. TREATMENT AND ITS GROUND (FOR THE DISEASE IN GENERAL AND FOR THE PRESENT ONE IN PARTICULAR) Regimen Diet Drugs with prescriptions 35 XII. SUMMARY (Lat. Epicrisis) 36 Навчальне видання Макєєва Наталія Іванівна Ярова Катерина Костянтинівна Алєксєєва Наталія Павлівна Піддубна Ірина Миколаївна Афанасьєва Оксана Олександрівна НАВЧАЛЬНА ІСТОРІЯ ХВОРОБИ З ПЕДІАТРІЇ (4 курс – Педіатрія, 5 курс – Хвороби системи крові у дітей) Робочий зошит для студентів Відповідальний за випуск Н. І. Макєєва Комп'ютерна верстка О. Ю. Лавриненко Формат А5. Ум. друк. арк. 2,3. Зам. № 21-34149 ______________________________________________________________ Редакційно-видавничий відділ ХНМУ, пр. Науки, 4, м. Харків, 61022 izdatknmurio@gmail.com ________________________________________________________________________________ Свідоцтво про внесення суб’єкта видавничої справи до Державного реєстру видавництв, виготівників і розповсюджувачів видавничої продукції серії ДК № 3242 від 18.07.2008 р