5 Part I. Scheme of student's case history




Название5 Part I. Scheme of student's case history
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CONTENTS

Preface

5

Part I. Scheme of student's case history:

6-16

Tittle page

6

I. General information

7

II. Complaints

7

III. Anamnesis morbi

7

IV. Anamnesis vitae

8-10

V. Physical examination

10-15

VI. Provisional diagnosis

15

VII. Plan of laboratory and instrumental examinations

15

VIII. Laboratory findings

15

IX. Cursus morbi (diary)

16

X.. Differential diagnosis

16

XI. Final diagnosis

16

XII. Treatment and its ground

16

XIII. Literature data on the present disease

16

XIV. Prognosis

16

XV. Epicrisis

16

XVI. Bibliography

16

XVII. Student’s signature

16

^ Part II. Recommendations for student's case history writing

17-18

Part III. Short vocabulary for using in the clinic

19-64

I. Anatomical terms:

19-20

^ II. Useful questions for obtaining case histories

21-30

III. Common findings on examination

31-35

IV. Investigations

35-38

V. Some common investigation results

38-40

^ VI. Drugs

40-42

VII. Medical conditions

42-48

VIII. Medical abbreviations

48-64

Literature

65


СОДЕРЖАНИЕ

Предисловие

5

^ Часть I. Схема учебной истории болезни

6-16

Титульный лист

6

I. Общие сведения о больном

7

II. Жалобы

7

III. Анамнез болезни

7

IV. Анамнез жизни

8-10

V. Физикальные данные

10-15

VI. Предварительный диагноз

15

VII. План лабораторного и инструментального обследования

15

VIII. Результаты лабораторного обследования

15

IX. Дневники курации

16

X. Дифференциальный диагноз

16

XI. Окончательный диагноз

16

XII. Лечение и его обоснование

16

XIII. Обзор литературы по данному заболеванию

16

XIV. Прогноз

16

XV. Эпикриз

16

XVI. Использованная литература

16

XVII. Подпись студента

16

^ Часть II. Рекомендации по написанию учебной истории болезни

17-18

Часть III. Короткий словарь для использования в клинике

19-64

^ I. Анатомические термины

19-20

II. Стандартные вопросы при заполнении истории болезни

21-30

III. Общие данные при обследовании

31-35

^ IV. Исследования

35-38

V. Некоторые общие результаты исследования

38-40

^ VI. Лекарства

40-42

VII. Патологические синдромы

42-48

VIII. Медицинские аббревиатуры

48-64

^ Список литературы

65


PREFACE
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

^ SUMY STATE UNIVERSITY

MEDICAL INSTITUTE

DEPARTMENT OF PEDIATRICS WITH COURSE OF MEDICAL GENETICS

STUDENT’S CASE HISTORY (SCH)
Patient’s name and age_______________________
Diagnosis:_________________________________
Student (In Charge): _______________
Group____________________________

Course (year)____________________
Teacher__________________________

Date of giving the SCH for checking up

_______________________________

Mark

Teacher's Signature________________
Date «__»___________________200_

^ SUMY-200_
I. GENERAL INFORMATION

Name _______________________________________________

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)_______________

________________________________________________

Their duration.

^ III. ANAMNESIS MORBI

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.

^ 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.

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).

The children in their order, with details of age and health, and including death, stillbirth, and abortions.
^ PEDIGREE CHART

Standard symbols for pedigree charts:

- Unaffected male

- Affected male

- Abortion

- Unaffected female

- Affected female

- Sex unknown

- Stillbirth

- 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.

E. Habits

  • Eating: appetite, food dislikes, feeding habits of child’s parents.

  • Sleeping: hours, disturbances, snoring, restlessness, dreaming, and nightmares.

  • Exercise and play.

  • Urinary, bowel.
    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).
^ V. PHYSICAL EXAMINATION
Temperature, pulse rate, respiratory rate, blood pressure, weight, height, head circumference (The results of investigations must be compared with age standards).

GENERAL APPEARANCE

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.
SKIN

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.
^ 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).
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 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, drunting, type of cry, speech).
EAR

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, bruit, isthmus, nodules, tenderness), lymph nodes, veins, position of the trachea, sternocleidomastoid muscle (swelling, shortening), webbing, edema, auscultation, movement, tonic neck reflex.

THORAX

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.
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, 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.
^ 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.
LUNGS

Type of breathing, dyspnea, duration of expiration, cough; expansions, local fremitus; flatness or dullness to percussion, resonance, breath and voice sound, rales, crepitation, wheezing.

Percussion: inferior border of the lungs

Border

Right lung

Left lung











^ 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: 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.
ABDOMEN

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.

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, 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.
^ VI. PROVISIONAL DIAGNOSIS

(Diagnosis based on the facts of the Case History and Physical Examination).


  1. PLAN OF LABORATORY AND INSTRUMENTAL EXAMINATIONS




  1. LABORATORY FINDINGS




  1. ^ CURSUS MORBI (DIARY)




Date

Results of examinations of patient

Prescription

1.







2.







^ X. DIFFERENTIAL DIAGNOSIS
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).

^ XIV. PROGNOSIS
XV. EPICRISIS
XVI. BIBLIOGRAPHY (list of used literature)
XVII. STUDENT’S SIGNATURE

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