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Pediatric Patient Case History 2009

Pediatric Patient Case History 2009

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Published by Deepankar Srigyan

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Categories:Types, Research
Published by: Deepankar Srigyan on Apr 15, 2009
Copyright:Attribution Non-commercial

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01/31/2013

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PEOPLE’S FRIENDSHIP UNIVERSITY OF RUSSIA
FACULTY OF MEDICINEDEPARTMENT OF PEDIATRICSHEAD OF DEPARTMENT- Проф. КУЗМЕНКО Л.Г.
PATIENT CASE HISTORY
NAME OF PATIENT: КАТАЛЬНИКОВ ИГОРЬ АНАТОЛОВИЧ
Преподаватель:Асс.Доц. Контемирова М. Г.
Сurator- Deepankar SrigyanGroup- ML 511MOSCOW 2009
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Full name of Patient:
Katalnikov Igor AnatolovichAge (date of birth): 1 yr. 5 months (05-10-2007).Nationality: RussianDate of admission: 03-04-2009 at 20²⁰.Date of starting of curation: 07-04-2009 at 12 AM.
Diagnosis at admission:
Exudative pericarditis.
Clinical Diagnosis:
Subacute non-specific exudative pericarditis.ANAMNESIS OF THE DISEASEChild was admitted from 14-02-09 to 03-03-09 in the 5
th
departmentof this hospital with diagnosis of exudative pericarditis and afterconsultation of surgeon this child admitted in this department on03-04-09 and here the clinical diagnosis is Subacute non-specificexudative pericarditis.Complains: there is no any complain according to child’s mother.
I.
STATUS PRESENCE
General state:
moderately severe at the time of admission.
Position of the patient:
active
Body Constitution:Parameters:In normal-Of patient-
Body height80 cm.83 cm.Body weight12.7 kg.12 kg.Circumference of head48 cm.47 cm.
2
 
Circumference of chest52 cm.56 cm.
Physique(body build):
normosthenic.
Skin:
dry, pale-pink, mucous clean.
Subtaneous fatty layer:
moderate & equal development. Turgor of the tissues: normal satisfactory; no oedema; normalelasticity of skin.
Lymphatic nodes:
lymph nodes are not palpable.
Muscular system:
moderate development, tonus & force normal.
Skeletal system:
 skull well developed,fundicular constitution: Size- 47 cm., skullsutures stabilized. Thorax: closer to cylindrical form.Vertebral column: is normal.Extremities: unchanged. Joints: unchanged, free movements of joints.
Respiratory system:
  Type of respiration: thoracic; nasal respiration free, no dischargefrom nose. Respiratory rate- 24 per min.Voice: clear, Cough and dyspnoea are absent. Vocal tactile fremitusnot changed; Bronchophonia(vocal resonance) not changed.Lungs:On comparative percussion- pulmonary/clear percussion noteover the entire surface.Lower borders of lungs :
LinesRightLeft
Midclavicular line6
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ribLower border of leftlung along themidclavicular lineremarkable awayfrom sternum atheight of 4
th
rib andsharply goes down.Mid-axillary line8
th
rib9
th
ribScapular line9
th
-10
th
rib10
th
rib
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