Pediatric Status Presence
-
Upload
deepankar-srigyan -
Category
Documents
-
view
106 -
download
0
Transcript of Pediatric Status Presence
![Page 1: Pediatric Status Presence](https://reader036.fdocuments.in/reader036/viewer/2022081813/548bec7bb4795927238b460e/html5/thumbnails/1.jpg)
PEOPLE’S FRIENDSHIP UNIVERSITY OF RUSSIA
FACULTY OF MEDICINE
DEPARTMENT OF PEDIATRICS
HEAD OF DEPARTMENT- Проф. КУЗМЕНКО Л.Г.
STATUS PRESENCE
NAME OF PATIENT: ПЕТРОВИЧЕВА ТАТЬЯНАСЕРГЕЕВНА
Преподаватель:Асс.Доцент КУТАФИН Ю. Ф.
Сurator- Deepankar Srigyan
Group- ML 511
MOSCOW 2008
![Page 2: Pediatric Status Presence](https://reader036.fdocuments.in/reader036/viewer/2022081813/548bec7bb4795927238b460e/html5/thumbnails/2.jpg)
Full name of Patient: Petrovicheva Tatyana Sergeevna
Age (date of birth): 13 yrs (02-04-1995)
Nationality: Russian
Date of admission: 04-11-2008 at 11 AM
Date of starting of curation: 12-11-2008 at 12AM
Clinical Diagnosis: Congenital Heart Defect
STATUS PRESENCE
General state: satisfactory
Position of the patient: active
Body Constitution:
Parameters: In normal- Of patient-
Body height 153 cm. 163 cm.
Body weight 34-36 kg. 38 kg.
Circumference of head 55 cm. 55 cm.
Circumference of chest 69 cm. 65 cm.
Physique(body build): asthenic.
Skin: dry, pale-pink, with itching shade on upper & lower limbs.
Subtaneous fatty layer: moderate & equal development.
Turgor of the tissues: normal satisfactory; no oedema; normal elasticity of skin.
Lymphatic nodes: mandibular lymph nodes are palpable, 4-6 in numbers, with low consistency & free mobility, low sensibility.
Muscular system: moderate development, tonus & force normal.
![Page 3: Pediatric Status Presence](https://reader036.fdocuments.in/reader036/viewer/2022081813/548bec7bb4795927238b460e/html5/thumbnails/3.jpg)
Skeletal system:
skull well developed,fundicular constitution:Size- 55 cm.,skull sutures stabilized. Thorax: closer to cylindrical form, deformed at xiphoid process of sternum. Vertebral column: presence of scoliosis at thoracic vertebral column. Extremities: unchanged, left side shoulder down. Joints: unchanged, free movements of joints.
Respiratory system:
Type of respiration: thoracic; nasal respiration free, no discharge from nose. Respiratory rate- 20 per min.
Voice: clear, Cough: dry, Respiration: equal but difficult(dyspnoea) on physical heavy work. Vocal tactile fremitus not changed; Bronchophonia(vocal resonance) not changed.
Lungs:On comparative percussion- pulmonary/clear percussion note over the entire surface.
Lower borders of lungs : In Normal-
Lines Right Left
Midclavicular line 6th rib Lower border of left lung along the midclavicular line remarkable away from sternum at height of 4th rib and sharply goes down.
Mid-axillary line 8th rib 9th rib
Scapular line 9th -10th rib 10th rib
Paravertebral line At the level of spinous process of 11th thoracic vertebrae.
At the level of spinous process of 11th thoracic vertebrae.
![Page 4: Pediatric Status Presence](https://reader036.fdocuments.in/reader036/viewer/2022081813/548bec7bb4795927238b460e/html5/thumbnails/4.jpg)
Lower borders of lungs : In Patient-
Lines Right Left
Midclavicular line 6th rib Lower border of left lung along the midclavicular line remarkable away from sternum at height of 4th rib and sharply goes down.
Mid-axillary line 8th rib 9th rib
Scapular line 10th rib 10th rib
Paravertebral line At the level of spinous process of 11th thoracic vertebrae.
At the level of spinous process of 11th thoracic vertebrae.
Mobility of lung’s borders: 0.5-1.0 cm.
Character of breathing: vesicular breathing, dry rales.
Circulatory organs:
Visible chest deformity at lower sternal region, postoperative scars present; Vessels of neck are not visible but jugular veins are palpable. Apex beat heard at 5th intercostal space 0.5 cm. inside from midclavicular line.
Borders of absolute dullness of heart:
Borders: In normal- In patient-
Upper 4th rib 4th rib
Left Between midclavicular & parasternal line, nearer to parasternal line.
Between midclavicular & parasternal line.
Right Left border of sternum. Left border of sternum.
Borders of relative dullness of heart:
![Page 5: Pediatric Status Presence](https://reader036.fdocuments.in/reader036/viewer/2022081813/548bec7bb4795927238b460e/html5/thumbnails/5.jpg)
Borders: In normal- In patient-
Upper 3rd rib 3rd rib
Left 0.5 cm inside from left midclavicular line.
On midclavicular line.
Right Right border of sternum Right border of sternum
Apex beat 0.5 cm inside from left midclavicular line at 5th intercostal space.
On midclavicular line at 5th intercostal space.
Tones: noisy and rhythmic.
Sound: systolic murmurs at apex on midclavicular line at 5th intercostal space.
Pulse: rhythmic, frequent, uniform. Pulse rate- 90/min.
Arterial blood pressure: 110/70 mmhg.
Digestive organs:
Lips: pink, moist; Tongue: clean, moist. Buccal mucosa and gums are healthy; Oro-nasopharynx is clear, tonsils are normal; Number of teeth- 28 are permanent,clean & healthy. Abdomen symmetrical, oval shaped,scars absent. State around the umbilical region: hernias absent. Appetite normal, eating 3-4 times in a day. Liver is palpable 1 cm below the costal margin, dense, smooth, absence gravity of pain.Spleen is not palpable. Stool: frequency- 1 time in a day, formed, soft consistency, brown colour, without tenderness of defaecation, condition of rectum is good.
Urogenital system:
![Page 6: Pediatric Status Presence](https://reader036.fdocuments.in/reader036/viewer/2022081813/548bec7bb4795927238b460e/html5/thumbnails/6.jpg)
Type of urinary passage- free, 5-6 times in a day.Pasternsky's symptom absent. Urine: light yellow color, full transparent; Specific gravity of urine- 1020.
Development of sex organs: SMR Stage(Sexual maturity rating)- 3, Breast and areola enlarged,no contour separation; pubic hairs appeared and secondary sexual signs are well visible.
Neurological and endocrine system:
Sense organs: eyes- good visual acuity, good condition of conjunctiva and pupil. Ears- good audition, the condition of pinna & external meatus is good. Conciousness clear, good intellect, good mood & clear speech.Sensitivity of tactile, painful and temperature is normal. Pathological reflexes (hyperkinesias, tremors) are absent.
Condition of endocrinal glands is good.
THE LITERATURE USED:
1. Essential pediatrics,6th edition by O.P.Ghai, Piyush Gupta and V.K.Paul, CBS Publishers, India,2008.2. Детские Болезни:Учебник,часть-1, . ., . .,ТюринНА Кузьменко ЛГ М.:Изд-во РУДН,2004.-610 с.3. Class materials given by Асс. . . Доцент КУТАФИН Ю Ф And
. . , КонтемироваМГ РУДН.4. Tsepova E.L. Recording patient’s case report (information book for the third year foreign medical students). – Smolensk: SSMA, 2004. – 58 p.5. Macleod’s Clinical Examination // Edited by John F. Munro, Ian W. Campbell / Tenth edition. – 2000. – 312 p.