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Recent changes in the field of medical education, orientation on ESTS (European Credit Transfer System) have profoundly influenced pediatrics.
This edition first of all has the aim to help the medical students studying pediatrics in English to overcome the problems of intercourse with patients in a children’s clinic and write training students’ case history.
Our hope is that text will serve as a useful tool for students and residents.
Part I. Scheme of student’s case history.
Form of Case history:
Ministry of Health of Ukraine
DEPARTMENT OF PEDIATRICS WITH COURSE OF MEDICAL GENETICS
STUDENT’S CASE HISTORY (SCH)
Patient’s name and age_______________________
Student (In Charge): _______________
Date of giving the SCH for checking up
Age, date of birth_________________________________
Address_____________________________________________Telephone___________________________________________Date and time of admission__________________________
By what medical establishment was directed to hospital__________________________________________
________________________________________________With what diagnosis________________________________
II. COMPLAINTS (at time of admission)_______________
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.
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).
^ 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.
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).
The children in their order, with details of age and health, and including death, stillbirth, and abortions.
Standard symbols for pedigree charts:
- Unaffected male
- Affected male
- Unaffected female
- Affected female
- Sex unknown
- Death in infancy
- Unknown whether individual affected
- Marriage coupling bar
- Consanguineous marriage bar
- Brother and sister relationship
Sibs hip of which details are unknown or only the number is known:
- Identical twins
- Non-identical twins
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.
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).
Temperature, pulse rate, respiratory rate, blood pressure, weight, height, head circumference (The results of investigations must be compared with age standards).
Does the child appear well or ill.
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.
Color (cyanosis, jaundice, pallor, and erythema), texture, eruptions, hydration, edema, hemorrhagic manifestations, scars, dilated vessels and direction of blood flow, hemangiomas, nevi, Mongolian (blue-black, coffee-like) spots, pigmentation, turgor, elasticity, and subcutaneous nodules. Striae and wrinkling. Sensitivity, hair distribution, character, and desquamation.
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).
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.).
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.
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).
Exterior, shape, mucosa, patency, discharge, bleeding, pressure over the sinuses, flaring of the nostrils, the septum.
The tonsils (size, inflammation, exudates, crypts, inflammation of the anterior pillars), mucosa, hypertrophic lymphoid tissue, postnasal drip, epiglottis, voice (hoarseness, stridor, drunting, type of cry, speech).
The pinnas (position, size), canals, tympanic membranes (landmarks, mobility, perforation, inflammation, discharge), mastoid tenderness and swelling, hearing.
Position (torticollis, opisthotonos, inability to support the head, mobility), swelling, the thyroid (size, contour, bruit, isthmus, nodules, tenderness), lymph nodes, veins, position of the trachea, sternocleidomastoid muscle (swelling, shortening), webbing, edema, auscultation, movement, tonic neck reflex.
Shape and symmetry, the veins, retractions and pulsations, heading, Harrison’s groove, flaring of the ribs, pigeon breast, funnel shape, size and position of the nipples, breasts, length of the sternum. Intercostal and substernal retraction, asymmetry, the scapulas, clavicles.
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, rheumatic nodules, carrying angle of the elbows, tibiatorsion.
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, dermatoglyphics, the width of the thumbs and big toes, syndactily, length of various segments, dimpling of the dorsa, temperature.
D. Peripheral vessels: presence, absence or diminution of arterial pulses.
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.
Type of breathing, dyspnea, duration of expiration, cough; expansions, local fremitus; flatness or dullness to percussion, resonance, breath and voice sound, rales, crepitation, wheezing.
Inspection and palpation of the heart area (apex beat, cardiac humpback, murmurs, etc.).
Auscultation: quality of heart sounds, compared with pulse as to rate and rhythm. Murmurs (location, position in cycle, intensity, pitch, effects of change of position, transmission, and effect of physical exercises). Blood pressure.
Size and contour, visible peristalsis, respiratory movement, the veins (distention, direction of flow), umbilicus, hernia, musculature, tenderness and rigidity, tympana, shifting, dullness, rebound tenderness, pulsation, palpable organs or masses (size, shape, position, mobility), fluid wave, reflexes, bowel sounds.
Size (palpation, percussion). Tenderness. Surface. Inferior margin.
Palpable or not. Size, surface, tenderness.
Urination. Frequency, painfulness, retention of urine. Pasternatsky’s sign. Genitalia. Abnormal development.
RECTUM AND ANUS
Irritation, fissures, prolapse, anal atresia (in newborns).
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.
(Diagnosis based on the facts of the Case History and Physical Examination).
XI. FINAL DIAGNOSIS (TO GROUND)
XII. TREATMENT AND ITS GROUND (FOR THE DISEASE IN GENERAL AND FOR THE PRESENT ONE IN PARTICULAR)
XIII. LITERATURE DATA ON THE PRESENT DISEASE (etiology, pathogenesis, clinical manifestations, classification, treatment, and prevention in general and concerning the present patient).
XVI. BIBLIOGRAPHY (list of used literature)
XVII. STUDENT’S SIGNATURE
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