THE CASE HISTORY SCHEME

Kyiv State Hospital

Pediatric department №1

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 The Head Of Department: Prof.Brezhk.V.S
 The Physician (teacher): Gorobec A.O.
Dmytro Minchenko
 The Patient: Soproninko Alona
 Diagnosis: Acute respiratory viral disease: acute rhinitis, acute
pharyngitis
 The date of curation: may 2, 2020
  Babazadeh Mohammadreza,faculty of biology medicine,Group1, 3rd year

Fatemeh Bemana Group 5

 1. PASSPORT DATA

 Soproninko Alona
 2016 August 13 in Saturday , 3 years old, 8 months and 26 days
 Kyiv, Reheneratorna St, 4,
 May 2, 2020, 10:00 a.m.
 Attended by general doctor

II

her Parents explain problem that were a runny nose, cough when she wake up ,
headache, difficulty swallowing
Increase body temperature 38.5 ° C Tiredness, sneezing

Certain systems and organs questioning:

Blood circulation system

No significant changes were observed
Respiratory organs
dry Cough (Dry coughs indicate upper airway inflammation),
In Laryngeal have seen edema, narrowed lumen of the larynx.
A sore throat pain felt in the throat. Redness of the throat and tonsils
Night sweats seen

Fever: 38,5

Dyspnea: physical exertion ore anxiety inspiratory dyspnea appears

Breathing through the nose: difficulty Discharge from the nose is moderate, mucous in nature. runny
nose

Nasal congestion due to blockage of the nasal passages .

Voice is whispering hoarse like

we are not seen Pain in the chest , hemoptysis, Nasal bleedings

Digestive organs
Pain in the abdomen : none Feeling of fullness;
Dyspeptic disorders: non
appetite: normal;
aversion for certain food - none;
defecation: regular, once a day.
Touch in the mouth absent
; belching - none;
heartburn: none;
Nausea: none;
vomiting: none;
meteorism - none;
excrements: regular;
constipations; diarrhea - none;
Urinary system
Pain: non
Urination: 3-4 times a day,
Disuric symptoms: enuresis, pain, false feeling of urination, etc.
Urine: the color of the urine is straw-yellow .Morning urine is darker in color
Edemas:non
We did not seen Itching , unpleasant smell from the mouth, diarrhea
 Nervous system and sensor organs
Child is fatigue fell with normal sleep

Headaches are often concentrated in the forehead.

Violations ща Vision ,Sensitive sphere , hyposthesias, hypersthesias, skin itching are not detect

audition Sound bass middle ear, taste It feels tasteless when eating certain foods

Bone and muscular system

Pain: In proportion to muscle pain Joint pain

Neither hypotrophy nor hypertrophy is detected.

III. ANAMNESIS OF THE DISEASE (ANAMNESIS MORBI)

The disease began on the 29 of Aril with fatigue, feeling cold, sneezing and headache, and intensified
after three days Other symptoms, such as runny nose and cough, followed

All of these symptoms occurred after playing in a relatively cold environment

IV. ANAMNESIS OF LIFE (ANAMNESIS VITAE)

she is the first child in the family and has had a normal delivery 273 days or 39 weeks

at born, weight was 3100g., Growth 52cm she did not have a specific illness or problem at birth and was
normal she received all type of vaccine which were require

 Birth
o Vaccine:
 Hepatitis B
 2 months of age
o Vaccine
 DTaP - Diphtheria, Tetanus, Acellular Pertussis
 IVP - Inactivated Polio vaccine
 Hepatitis B
 Pneumococcal vaccine
 HIB - Haemophilus influenza Type B
  Rotavirus vaccine
 4 months of age
 DTaP
 IVP
 Pneumococcal vaccine
 HIB
 Rotavirus vaccine
 6 months of age Vaccine
 DTaP
 IVP
 Hepatitis B
 Pneumococcal vaccine
 HIB
 Influenza vaccine**
 Rotavirus vaccine
 12 months of age Vaccine
 MMR - Measles, Mumps, Rubella
 Pneumococcal vaccine
 Hepatitis A

she had traveled with his family She had contracted the disease while traveling before

The parents had no genetic problems

her place of residence is relatively cold and her house is near a large river

she is very interested in sweets And it usually eats a lot and also was not allergic to any particular drug

V. PATIENT STATE AT THE MOMENT OF EXAMINATION (STATUS

PRAESENS OBJECTIVUS)
General condition is satisfactory. The attitude to the inspection is adequate. Consciousness is clear.
Weight - 14.2kg, height - 94cm, head circumference - 50cm, chest circumference - 49cm.

Position of the child in the bed - passive.

Nervous system: Violations from the side of vision, hearing, smell, taste - not detected. Tendon,
pupillary reflexes are symmetrical, live. Sweating is moderate. The condition of the hairline is normal.
Appearance corresponds to age.

The skin is pale.Visible mucous membranes are wet.

Subcutaneous fat is satisfactorily developed. No swelling. In the throat - hyperemia of the posterior
pharyngeal wall. Peripheral lymph nodes are not enlarged, painless on palpation. Musculosceletal
system: The muscles are well developed, the tone is normal. The joints and bones are not changed, the
movements are free. - Head circumference - no deformation - Face: expression normal. No butterfly
wings color, no acromegalic , symmetric. - Eyes: green color of sclera, no hemorrhages, eye movement is
not defected. - Nose: is participation in breathing , no deformation, skin color. - Neck: no swallow ,
pulsation of carotid vessel is normal, thyroid gland size is normal. - Oral cavity and mucous tunics:
reddish color, no ulcerations, mild pigmentation, red color, carious teeth, tongue size is normal
peculiarities, slightly enlarged tonsils . palpation of the submandibular lymph nodes, the latter are
moderately enlarged, painless, with a dense-elastic consistency, not fused with the underlying tissues

Respiratory organs investigation

Form of the chest - normostenic, symmetrical. Respiratory rate 35 per minute.

The width of the intercostal spaces is 1 cm. The shoulder blades fit snugly. The supraclavicular and
subclavian fossae are weakly marked, expressed equally on the right and left.

The breath is superficial, rhythmic. The movement of the chest during breathing is similar.

The chest on palpation is painless, elastic. Voice jitter on both sides is the same. With comparative
percussion in symmetrical areas, a clear pulmonary sound is determined over the entire chest; with
percussion, pain is noted in the upper chest on both sides Percussion The lower boundaries of the lungs:
line left to right l.parasternalis 5 intercostal space - l.medioclavicularis 6 rib - l.axillaris anterior 7 rib 7
rib l.axillaris media 8 rib 8 rib l.axillaris posterior 9 rib 9 rib l. scapularis 10 rib 10 rib l.paravertebralis ost.
process 11 gr. call rest process 11gr.

Lung auscultation may reveal wheezes, as well as rhonchi that typically improve with coughing

Cardiovascular system investigation

Pulse - 95 / min, rhythmic, synchronous, satisfactory filling and voltage.

The wall of the artery is elastic.

Ripples and bulges of the cervical veins are not observed, there is no "heart hump".

The lumbar region on palpation is painless.

The apical impulse is located in the V intercostal space on the left along the medianclavicular line,
unbroken, resistant, low, with an area of 2 square cm.

Absolute cardiac dullness:

- right: on the left edge of the grains.

- left: in the middle between the left medianclavicular and periosternal lines.
 - top: in the 3rd intercostal space.

The boundaries of relative cardiac dullness:

- right: inwards from the right periosternal line

- - left: along the midclavicular line.
- - upper: in the 2nd intercostal space.

On the top and bottom of the heart 2 tones are heard: I tone - low, long, clear; IIton - tall, short, clear.
Rhythmic tones, no side noises.

Abdominal cavity organs investigation

The appetite is normal.

Chewing normal ,
Swallowing little painful, and passage of food through the esophagus are not disturbed
Investigation of spleen liver, pancreas gall bladder No significant changes were observed.

Liver: The lower edge of the liver of normal consistency, a round shape, painless,
protrudes 2.5 cm from the edge of the costal arch
Gallbladder: The gall bladder is not palpable. There is no pain on palpation at the
point of the gallbladder

other investigation

General blood test from: Hemoglobin 137g / L Red blood cells 3x10¹² / l Color indicator 0.9 ESR
mm / h Platelets 270x109 / L White blood cells 4x109 / l Eosinophils 1 Basophils - Myelocytes 0
Metamyelocytes 0 Segmented 33 Lymphocytes 59 monocytes 7

X-ray examination
the pulmonary fields are clean, the pulmonary pattern is strengthened. The roots are quite structural.
Shadows of the mediastinum without features. Sinuses are also without features
 Primary diagnosis composition
On the basis of child’s complains of runny nose, cough especially after wake up, headache, difficulty
swallowing Increase body temperature 38.5 ° C Tiredness, sneezing taking into account anamnesis
morbi data such as, feeling cold, sneezing and headache, and intensified after three days play in cold
wether and anamnesis vitae data such asLack of postpartum problems and lack of genetic problems in
the family and no drug allergies;

taking into consideration the results of objective investigation (Lack of postpartum problems and lack of
genetic problems in the family and no drug allergies dry Cough In Laryngeal have seen edema,
narrowed lumen of the larynx. A sore throat pain felt in the throat. Redness of the throat and tonsils
Lack of digestive problems and lack of problems in X-rays and Test results of blood tests and the
presence of a viral infection and fever 38.5), it is possible to make a primary diagnosis of the disease:
Acute respiratory viral disease: acute rhinitis, acute pharyngitis

- main respiratory viral disease

- complications of main disease acute rhinitis, acute pharyngitis

Curator’s signature