Nursing medical history in pediatrics
1. PASSPORT PART
Surname, name, patronymic: Morozova Irina Aleksandrovna
Age: 3 years old
Date of receipt: 19.09.2012
Age of parents: mother - 24 years old Morozova Elena Andreevna,
father - 44 years old Morozov Alexander Igorevich.
The child attends kindergarten.
Home address: Chelyabinsk region. Kyshtym st. Lenina 67a kv 21

2. COMPLAINTS.
Complaints at admission: general malaise, headache
pain, fever up to 38.8 C, runny nose, constant dry
cough, palpitations, shortness of breath.

Complaints at the moment: general weakness, poor appetite,
nasal congestion, fatigue, dizziness, hysterical
dry cough.
3. Anamnesis of life.
(according to mother).

1) Hereditary history.

Mom is 24 years old, dad is 44 years old. The girl's parents are healthy (according to
mothers). Among the diseases of relatives, he notes coronary artery disease, strokes,
gastritis. He reports that there are many centenarians among his relatives.
Bronchial asthma, allergic diseases, obvious hereditary
diseases, endocrine diseases, tuberculosis, mental and
venereal diseases in relatives denies. Presence in the genus
miscarriages and stillbirths, non-viability of children, congenital
deformities, unusual course of diseases also denies. Pedigree
families are relatively favorable.

2) Social history.

There are 3 people in the family: father, mother and child. In a family, sometimes parents
drink alcohol, mom smokes. Psychological climate in the family
calm. Grandma helps take care of the baby. Housing and household
conditions are generally accepted. Sanitary and hygienic
conditions (sleep pattern, provision of clothes, furniture, toys)
satisfactory. Nutrition: up to 7 months the child was on
breastfeeding: with correction after the first month (juices) and
the introduction of complementary foods (vegetable puree) from the 5th month, from the 6th month - the 2nd
complementary foods (cereals), and then switched to artificial nutrition. completeness
and diet after a year are observed. Appetite is good, loves sweets.
Allergy to citrus fruits is manifested by a rash on the skin of the face, trunk and
itching. From the age of 2 she attends a nursery.

3) Biological history.

A child from a third pregnancy that proceeded calmly in compliance with
regimen and doctor's recommendations; history of 2 abortions; monthly
was observed in the antenatal clinic, used maternity leave,
did not attend the young mother's school; first birth at 40 weeks
complications, it turned out to be a benefit. The child screamed immediately. Score by
Apgar score was 7-8 points. Height - 51 cm, body weight - 4130,
head circumference - 35 cm, chest circumference - 33 cm.
Immediately, the baby was actively sucking at the breast. Feeding on the first call
newborn. The initial weight loss was 680 g.
the first 6 months the child gained 900g. Falling off of the umbilical cord
Day 4, the umbilical wound healed by day 7. Newborn jaundice lasted 4
days, then disappeared (physiological jaundice). Discharged on day 7
body weight at discharge - 3680g. The state of lactation is satisfactory.
There were no diseases in the neonatal period. In a year the girl grew up
by 17 cm, weight was 11kg 630g, head circumference - 45 cm. Teeth became
erupt from 6 months, by the year - all 8 incisors. By 2 years - all 20
teeth. Neuropsychic development: at 3 months - fixed her gaze,
smiled, hummed, held her head well, an upper reflex appeared
Landau; at 6 months - turned in bed, looked towards the sound,
sat, played with toys, recognized familiar faces; at 7.5 months - became
pronounce individual syllables, babble; joined the lower reflex
Landau; at 9 months - understood speech, performed simple tasks,
uttered separate words, crawled quickly, stood with support; in
1.5 years - walked independently, squatted; at 3 years old - studies
the world around with the help of questions, running around, stubbornness appeared.
Preventive vaccinations were performed on time, tolerated them well.
The results of Mantoux reactions are negative.

Allergic history: drug allergy to penicillin,
an allergic reaction to citrus fruits in the form of a rash on the face, trunk and
itching.

From past diseases: frequent sore throats, acute respiratory viral infections, in July 2003 -
left-sided pneumonia, exacerbation of obstructive bronchitis,
left otitis. Hemotransfusions, as well as plasma transfusions and
the introduction of immunoglobulin was not carried out.

Epidemiological history: 09/17/2012 there was contact with an infectious
sick in children. garden (boy, 4 years old, presumably ARVI); in family,
There are no infectious diseases in the apartment.

State of health before the present illness: Obstructive bronchitis, remission (health group 3) - a state of subcompensation.

4) History of the disease.

The child has been sick since the age of 6 months, since March 2010, when
for the first time there was a runny nose, there was a temperature. As a result of the inspection
at home tutor The pediatrician was diagnosed with SARS. Appointed
treatment: ampicillin suspension, nasal drops, paracetamol. On the 2nd day
the child became covered with a rash, became restless, capricious. Was delivered
diagnosis: drug allergy to ampicillin; prescribed diphenhydramine and
within a day the rash disappeared, the child became calm. mom notes
frequent sore throats and acute respiratory viral infections in a child since the fall of 2010, which
accompanied by general malaise, fever, runny nose. AT
In the spring of 2002, a food allergy to citrus fruits was noted. After taking
orange juice, the girl became covered with a small punctate rash, became
act up. Uch. doctor - pediatrician prescribed suprastin, the rash disappeared
on the 2nd day. Since October 2010, SARS began to be accompanied by a long
dry cough that bothered the child for 1 month after
transferred SARS. In the spring and autumn of 2011, the girl suffered an acute
bronchitis. Observed on an outpatient basis. pediatrician; was appointed
treatment in the form of macrofoam in suspension, linkas syrup, ambrotex and
suprastin. Since the autumn of 2011, cough has become more disturbing
a long period of time (2 months from the moment of the disease): became
have the character of a painful dry cough. In July 2012 against the background
general malaise, fever, runny nose, cough and
dyspnea. The girl was hospitalized in the pulmonary department of the children's hospital,
where as a result of examination of the child and additional methods of examination
was diagnosed with left-sided focal pneumonia against the background of
chronic obstructive bronchitis, left-sided otitis. It was
treated with antibiotics, antihistamines,
bronchodilators and vitamin therapy. But mom notes that coughing and shortness of breath
disturbed the child for another 1 month from the date of discharge from
hospital. 09/17/2012, returning from children. garden home, she has
a runny nose appeared, reddened eyes; the next day - in the morning
(09/18/2012) cough appeared, the girl was left at home; and Friday afternoon
shortness of breath, in the evening the temperature rose to 38.8 C; parents called
ambulance, which the girl was taken to the emergency department
ODKB No. 2 at 23:00 on September 19, 2012, where she was injected intramuscularly with Sol.
Analgini 50% - 0.5 ml Sol. Papaverini hydrochloridi 2% - 0.5 ml Sol.
Dimedroli 1% - 0.5 ml and transferred to the 3rd department of this hospital. At
admission: 38.8o C, severe shortness of breath up to 40/min, tachycardia up to 120/min.,
the pharynx is brightly hyperemic. Above the lungs percussion clear pulmonary sound,
auscultatory - in the subscapular areas: unstable wet and
rare dry rales. Heart sounds are clear, rhythmic. Abdomen soft, liver
+1 cm, the spleen is not enlarged. There are no meningeal symptoms. Considering
complaints of the child, anamnesis of the disease, objective examination data,
fever, was diagnosed with chronic obstructive
bronchitis, exacerbation; DN -1, bilateral pneumonia and prescribed
treatment: antibiotics, bronchodilators, antihistamines and expectorants
means, inhalations with berodual and UHF on the area of ​​gr class.

The child's mother notes that by the time of curation, the girl's condition
somewhat improved. On the background of the prescribed treatment, normalized
temperature, headaches disappeared, general weakness, shortness of breath decreased,
cough; mucus started coming out. The cause of the exacerbation of the disease mother
associated with SARS.
4. Current inspection data.
General condition of moderate severity: shortness of breath, subfebrile temperature,
severe weakness, headache, decreased appetite. Position
the patient is active. Physique is normosthenic, the patient is normal
nutrition. Physical development is average, harmonious. Body weight - 13 kg,
body length - 94 cm. The child develops in accordance with the age
the norm. Stigmas of dysembryogenesis were not detected.

Nervous system: consciousness is clear, reaction to others is adequate,
calm behavior, good mood, sociable, mental
development is age appropriate. There are no changes from the side of the CHM. Dermal
abdominal and tendon reflexes alive, D=S. Meningeal symptoms
(rigidity of the occipital muscles, S. Kernig, S. Brudzinsky, etc.) and
symptoms of tension of the nerve trunks (symptoms of Lassegue, Matskevich,
Wasserman) are absent. Coordination tests: finger-nose,
heel-knee are satisfactory, stable in the Romberg position. Gait
normal, no frills. Dermographism mixed, appears through
15-16 seconds, lasts about 5 minutes.

The skin is pale, the humidity is slightly increased (he sweats a lot
during sleep), the skin is elastic, warm; there is moderate cyanosis
lips. Scars, rashes, hemorrhages, areas of pigmentation and depigmentation
not visible.

Subcutaneous fat: poorly developed, evenly distributed, no edema, no pastosity, normal tissue turgor.

Lymph nodes: submandibular lymph nodes are palpated
nodes 5-6 mm in size, painless, easily displaced; rest:
mental, occipital, cervical lymph nodes, supraclavicular and subclavian,
axillary, thoracic, cubital and inguinal are not palpated.

Muscles: symmetrically developed, normal tone, painless on palpation and movement, muscle strength is not reduced (5 points).

Skeletal system: developed proportionally, without signs of deformation,
the shape of the chest is barrel-shaped, symmetrical, curvature
the spine is not visually observed, the epigastric angle is straight.

Respiratory system: nasal breathing is difficult, from the nasal cavity -
mucous discharge. The type of breathing is mixed. NPV 21v min. breathing is rhythmic, deep, accompanied by a whistle, exhalation
elongated. Both halves of the chest take part in the act of breathing,
intercostal spaces are somewhat dilated, there is tension
serratus muscles evenly on both sides. Shortness of breath mixed with
the predominance of the expiratory component. The chest on palpation
painless. Voice trembling is symmetrical, slightly weakened. At
comparative percussion is determined by a clear pulmonary sound over all
lung fields. With topographic percussion, the lower border of the right
lung is determined by the mid-clavicular line - the upper edge 5
ribs, along the midaxillary line - 7th rib, along the scapular line -
upper edge of the 9th rib. The mobility of the pulmonary edge is 3 cm.

On auscultation of the lungs, intermittent dry whistling sounds are heard,
buzzing and creaking rales, better auscultated in the region of the 6th segment
(D=S) with increased breathing at the height of inhalation.

circulatory system. On examination of the cardiac region: cardiac
there is no hump. Cardiac impulse is not clearly palpable, apical
palpated in the fifth intercostal space 1 cm medially from the CL, localized. At
percussion: the upper limit of the relative dullness of the heart - in the second
intercostal space, right - 0.5 cm to the right from the right edge of the sternum, left -
1 cm outward from the mid-clavicular line. On auscultation of the heart
sonorous rhythmic tones are heard at all points of auscultation,
short functional noise at the apex and at the Botkin-Erb point (?).

The pulsation of the vessels of the neck is rhythmic, rapid, satisfactory
voltage. Pulse on the radial artery: frequency 110 per 1 minute, Ps (110):
NPV (24) \u003d 4.5: 1, rhythmic, frequent, average, satisfactory
tension and filling, synchronous on both hands.
Digestive system and abdominal organs. Red lips with
slight cyanotic tint, dry, slightly weathered. rashes,
ulceration, no cracks. The mucous membrane of the oral cavity and gums
pink, wet; hemorrhages, aphthae, ulcers, Filatov spots
noted. Tongue: tip pink from middle third onwards
lined with a loose whitish-yellowish coating. Cracks, ulcers, marks
no teeth, papillae slightly flattened. Dairy teeth. mucous membrane
the pharynx is hyperemic, the back wall of the pharynx is also hyperemic,
edematous, palatine tonsils are hypertrophied, protrude beyond the palatine
arches, hyperemic.

Abdomen of normal shape, symmetrical, not swollen, visible pulsation,
expansion of the veins of the anterior abdominal wall are absent, there are no scars,
Peristalsis is satisfactory (auscult.). percussion sound
tympanic. On palpation, the abdomen is soft, painless, symptom
there is no fluctuation. Symptoms of Shchetkin-Blumberg and Mendel
negative. The lower edge of the liver is painless, soft, elastic,
smooth, protrudes 1 cm from under the costal arch. The size of the liver
Kurlov: 8 cm, 6 cm, 5 cm. The spleen is not determined by palpation. Chair
daily, decorated, brown, without pathological impurities.

Given the history data: frequent sore throats, acute respiratory viral infections from 6 months
age, maternal smoking; data on the history of the development of the disease:
prolonged cough after the resolution of the next ARVI, on
over the past 2 years; the appearance of shortness of breath in 2003 against the background
bronchitis; polyvalent allergy: drug (drugs gr.
penicillin series) and food (citrus fruits; based on data
examination of the patient at admission: NPV=40 per minute; cyanosis of the nasolabial
triangle; skin is pale, moist. On auscultation -
breathing is hard; bronchospasm, scattered dry rales in the subscapularis
areas; change in the number of wheezing when coughing, you can put -

Provisional diagnosis:

Main disease: SARS. Chronic obstructive bronchitis, exacerbation.
Concomitant diseases: Polyvalent allergy: food, drug.
Complications: Respiratory failure - I.

Patient examination plan:
General blood analysis,
urine, general sputum analysis, biochemical blood test;
examination of feces for worm eggs and intestinal flora.
X-ray of the chest organs. Otorhinolaryngologist consultation.
Examination of respiratory function (spirography).
Results of laboratory, instrumental and other studies.
Complete blood count from 20.09.2012:
Hemoglobin 123 g/l
Erythrocytes 3.8*1012/l
CPU - 0.99
Leukocytes 9.6*109 /l
Band 3%
Segmented 54%
Eosinophils 6%
Lymphocytes 33%
Monocytes 3%
ESR 18mm/hour

Conclusion: leukocytosis, neutrophilic shift to the left, eosinophilia, accelerated ESR.

Urinalysis dated 20.09.12
Color - straw yellow;
transparent;
Relative density - 1021 (1010 - 10-25);
The reaction is acidic (weakly acidic, neutral)
Protein - no (N up to 0.033 g / l);
Epithelium squamous 0 - 1 in p / sp, transition. units in p / sp.
Leukocytes - unit. in the field sp. (up to 3 in p / sp.);
Conclusion: OAM within the age norm.

X-ray of the chest organs from 20.09.12:
On a chest x-ray in direct projection,
performed by rays of medium hardness, the strengthening of the pulmonary
pattern in root zones. The roots of the lungs are poorly structured.
There are no focal infiltrative shadows. The sinuses are free. Heart - within
age norm.
Conclusion: R-picture of ARVI, bronchitis.

Conclusion on all additional research methods: results
additional research methods indicate the presence
inflammatory process (moderate leukocytosis, increased ESR) in
lungs (an enhanced pulmonary pattern in the chest is determined on the x-ray
root zones).

Otorhinolaryngologist examination:
Nasal breathing is free, discharge is not abundant, mucous.
Oropharynx: hypertrophy of the palatine tonsils II stage, moderate hyperemia,
there are no flights. AD \u003d AS - b / n gray, shiny.
Diagnosis: o. rhinitis.

A diary.
09/22/12 t=36.9 RR=26 min HR=110/min.

General condition of moderate severity. There is no shortness of breath. Breathing through the nose
free, discharge from the nose is not abundant, mucous in nature. Cough
stopped being intrusive. The skin around the eyes has a bluish tint,
mild cyanosis of the nasolabial triangle; skin is clean, pale.
Zev is moderately hyperemic. Auscultation in the lungs dry
whistling and buzzing rales in the subscapular region. Heart sounds
sonorous, rhythmic. The abdomen is soft and painless. The chair is not broken.
Urination is normal.

09/23/12 t=36.7С NPV=24/min HR=98/min.

General condition of moderate severity. There is no pronounced dynamics. Sleeping
OK. Skin color is pale. Cough with a small amount
etc.................

BASHKIR STATE

MEDICAL UNIVERSITY.

DEPARTMENT OF CHILDREN'S DISEASES FOR MEDICAL

AND DENTAL FACULTY

Head department - prof. Etkina E.I.

Lecturer - Babenkova L.I.

DISEASE HISTORY

Curator: Afanasiev I.A.

Ufa 2003

PASSPORT PART.

1. Buryachenko Anastasia Dmitrievna

2. Age - 5 months, date of birth - 08.09.02

3. Gender - female

4. Date of receipt - 10.02.03

5. Home address - Ufa, B.Ibragimov street 37/2, apt. 13

6. The main diagnosis is SARS

7. Complications of the main diagnosis - acute obstructive bronchitis of moderate severity, respiratory failure of the 1st degree.

8. Concomitant - paratrophy of the 3rd degree, perinatal encephalopathy, hyperexcitability syndrome.

COMPLAINTS OF THE PATIENT.

Upon admission to the clinic: fever up to 37.5 C, cough, runny nose, hoarseness.

At the time of curation: redness of the skin in the area of ​​the intergluteal fold, moisture at the back of the head.

HISTORY OF THE PRESENT DISEASE.

According to the mother, the child has been ill for two weeks. The disease began with fever and cough. treated with cefazolin. After 8 days, the condition improved. Deterioration with severe cough began 4 days ago, treated with amoxiclav. On the fifth day, 10.02.03, they were sent to the hospital.

LIFE HISTORY OF THE PATIENT.

1. Information about the development and past diseases of the child.

The child was born from the first pregnancy. Childbirth at 37 weeks. The period from the onset of contractions to the onset of labor is 12 hours. Produced stimulation of labor activity. During pregnancy, the mother has anemia, the threat of interruption, preeclampsia of the 2 halves (dropsy).

Newborn condition.

Weight - 3350 g.

Height - 51 cm.

Head circumference - 36 cm

Chest circumference - 34 cm

First breastfeeding after 40 minutes

The umbilical cord fell off on the 6th day

BCG vaccination done on day 4

Discharged from the hospital on the 6th day.

The state of the newborn on the Apgar scale: 1 min - 6-7, 5 min - 6-7

Feeding a child.

The child is on mixed feeding.

From two months gets apple juice. From the age of five months she has been receiving Bebi milk formula, milk porridge, vegetable puree, apple puree.

Physical and neuropsychic development.

Smiling from 2 months

Holds head from 2.5 months

Gulit from 2 months

Tries to sit and crawl.

Past illnesses

Pneumonia (2 months), PEP, hyperexcitability syndrome

Preventive vaccinations

BCG - 4 days

DPT - 3 months, 4 months.

OPV-1 - 3 months

OPV-2 - 4 months.

allergic history.

Intolerance to individual foods is not noted. At 2 months he received amoxiclav, cefazolin. Allergological anamnesis of parents and relatives is not burdened. Living conditions - dry, warm apartment.

FAMILY HISTORY

The age of the father is 28 years old, the mother is 23 years old. The mother has chronic pyelonephritis. Heredity is not burdened. Bad habits of the father - smoking, moderate alcohol consumption, mother - smoking.

family tree diagram

The father works, the mother is on parental leave. Parents' education - secondary special. Living conditions are satisfactory, the child is provided with separate linen, a bed, and toys.

PATIENT STATUS.

General condition of the child.

During wakefulness, he is animated, hums for a long time, waves his toys.

Weight - 9800g.

Height - 67cm.

Head circumference - 44.5cm

Chest circumference - 47cm

Skin: pale skin, hyperemia in the area of ​​the intergluteal fold, moderate humidity. Elasticity is normal, soft tissue turgor is reduced. Pinch sign and hammer sign are negative. Dermographism is white, unspilled. The hair on the head is long and coarse. There are no vellus hairs on the back.

Subcutaneous fat: overdeveloped, unevenly distributed, more pronounced on the abdomen and thighs. Consistency - soft, "loose".

Muscles: the muscular relief is poorly expressed due to the excess subcutaneous fat layer. The belly is sagging. Muscle tone is reduced.

The volume of passive movements: in the elbow joint, extension up to 180 gr.

In wrist flexion up to 150 gr.

Breeding the hips - 75 grams in each direction.

Leg extension at the knee joint - 130g

Bending the feet - 120 gr.

The head may touch the acromial process with the chin.

When moving the hand to the opposite shoulder, the fingers reach the acromial process.

The volume of active movements in muscle groups and joints is not less than the volume of passive movements.

Skeletal system: the shape of the head is rounded, the circumference is 44.5 cm. Anterior fontanel - 2.5 * 2.5 cm.

Standards of physical development of girls 5 months, according to the city of Ufa.

Excess body weight - paratrophy 3 tbsp.

Physical development is disharmonious.

RESPIRATORY SYSTEM.

Inspection: The chest is cylindrical, without asymmetries and deformations. The epigastric angle is straight. Harrison's furrow is present. Breathing through the nose is difficult, the type of breathing is abdominal. Respiratory rate - 36 per minute, shallow breathing, non-rhythmic (34-48 per minute). Mucous discharge from the nose. Dry cough, severe inspiratory dyspnea.

Palpation: The chest is moderately pliable, elastic. Voice trembling is weakened over the entire surface of the chest.

Percussion: over the symmetrical areas of the chest, the percussion sound is pulmonary, with a box shade.

Topographic percussion: The upper border of the lungs. Both tops lag behind the clavicles by 2 cm. Posteriorly, the apices are determined at the level of the spinous vertebra. The width of the Krenig fields on the right and left is 3 cm.

Inferior border of the lungs

Auscultation: breathing is hard, increased. Rattling dry whistling over all lung fields.

THE CIRCULATION SYSTEM.

Inspection: The area of ​​the heart without protrusions. Apical and cardiac impulses are not visible.

Palpation: Cardiac impulse is not determined. The apical impulse is palpable in the 4th intercostal space 1 cm outward from the left midclavicular line, the impulse is low in height, of normal strength, limited. Heart rate 128 per minute.

Percussion: Borders of relative cardiac dullness. Upper - 3rd rib, left - between the left midclavicular and parasternal, closer to the midclavicular line. Right - the left edge of the sternum. The diameter of the blunting area is 3 cm. The width of the vascular bundle is 3 cm.

Auscultation: Heart tones are rhythmic, clear, sonorous. Noises are absent. Inwards from the sternocleidomastoid muscles, a weak pulsation of the carotid arteries is visualized. Outside of the same muscles, a negative venous pulse is palpated on the jugular veins. The pulse of the temporal arteries is palpated in the temporal fossae. The pulse of the femoral artery is at the level of the middle of the inguinal ligament. Pulsation of the epigastric region is not visualized.

Auscultation of vessels: tones and noises over the carotid arteries are not auscultated. Above the jugular veins, the "noise of the top" is not determined. Above the femoral arteries, the systolic tone, double Traube tone and Vinogradov tone are not heard.

SYSTEM OF DIGESTIVE ORGANS, ABDOMINAL AND RETROPERITONEAL SPACE.

The lips are red, of moderate moisture, without rashes, ulcerations, and cracks. The mucous membrane of the oral cavity is red, shiny. Zev is moderately hyperemic. The tonsils do not protrude beyond the temples. The tongue is clean and moist. Gums of physiological color. The mucous membrane of the pharynx is without features, there are no protrusions and lymphoid follicles on the posterolateral walls.

Abdomen: Right and left abdomen are symmetrical. The anterior abdominal wall extends beyond the plane, which is a continuation of the abdominal wall by 2 cm.

Percussion and tapping: The percussion sound over the stomach is low, tympanic, over the intestines is higher tympanic. Symptoms of Shchetkin-Blumberg and Mendel are negative. The abdomen is soft and painless.

There is no divergence of the rectus abdominis muscles. There are no swellings in the area of ​​the inguinal rings and the umbilicus.

Deep palpation: The sigmoid colon is palpated in the left iliac and left lateral regions in the form of a displaced cylinder. The caecum is palpated in the right iliac region in the form of a displaced cylinder with a pear-shaped extension. The terminal ileum is palpated as a rumbling and peristaltic cylinder with a smooth surface. The ascending, descending and transverse colons are palpated as soft cylinders, painless and rumbling.

Auscultation: Intermittent bowel sounds are heard. There is no friction noise from the abdominal wall.

LIVER AND GALL BLADDER.

Inspection: visually enlargement of the liver and pulsation of the liver are not determined.

Percussion: The upper border of the liver along the right anterior axillary line is the 7th rib.

On the right midclavicular line - 6th rib. The anterior median line is not defined.

The lower border of the liver along the right anterior axillary line is 1 cm below the right costal arch. On the right midclavicular line - 2 cm below the right costal arch. Along the anterior midline, 2 cm down from the xiphoid process. Ortner's sign is negative.

Palpation: the liver protrudes from under the edge of the costal arch along the midclavicular line by 2 cm. The edge of the liver is sharp, smooth, soft, painless. The surface is smooth. Kerr's, Murphy's and Mussy's symptoms are negative.

SPLEEN.

Apparent increase is not determined. On the back and right side is not palpable.

URINARY ORGANS.

There are no protrusions above the pubis, in the region of the kidneys. Tapping and palpation over the pubis is painless. Pal in the hypogastric region is painless. The kidneys are not palpated.

NERVOUS SYSTEM.

Daytime sleep - 3-4 times for 1.5-2 hours. Night sleep 8 hours. Neuropsychic development corresponds to age.

Visual and auditory functions without disturbances.

Pain, temperature and tactile sensitivity are detected.

General hand movements are age appropriate. There are no hyperkinesias. Dermographism white. Tendon reflexes are alive, uneven, have a wide zone. There are no meningeal symptoms.

PRELIMINARY DIAGNOSIS.

Based:

3. Information about the child's diseases - paratrophy, PEP

We exhibit preliminary diagnosis:

Associated Zab .: paratrophy 3 tbsp., PEP, hyperexcitability syndrome.

Obstructive bronchitis should be differentiated with pneumonia, bronchial asthma (asthmatic bronchitis), whooping cough.

SURVEY PLAN

3. Examination of feces for coprology, dysbacteriosis.

4. Chest X-ray. Fluorography of the mother's chest.

6. Consultation with an otolaryngologist.

ADDITIONAL RESEARCH

1. Complete blood count dated 12.02.03.

Hb - 133 g / l.

Er - 3.86x1012 / l

Lake. 6.9x109/l

ESR - 29 mm/hour

Lymph. – 66%

Mon. - 7%

2. General analysis of urine from 12.02.03

Yellow color

The reaction is alkaline

transparent

Protein - neg

Sugar - negative

Epithelial cells are polymorphic - 0-1 in the field of view

Leukocytes - 2-0-0 in the field of view

Erythrocytes - 1-0-0 in the field of view

Coprology from 13.02.03

No helminth eggs were found.

Neutral fats +

Undigested muscle fibers +

Bacteria +

ECG from 10.02.03.

sinus rhythm. Heart rate 130 bpm. Email axis is deflected to the right.

X-ray of the chest organs dated 10.02.03

The lung pattern is reinforced. Sinuses are free. The dome of the diaphragm is even. Heart shadow without features.

DIFFERENTIAL DIAGNOSIS

1. In acute pneumonia, characteristic of children 2-6 months old, an incubation period of up to 4-8 weeks is observed, a nonspecific onset of the disease (decreased appetite, lethargy, pallor, dyspeptic disorders), tympanic percussion sound, shortness of breath, painful, paroxysmal cough, hard respiration, on the x-ray - emphysema, abundant focal shadows with blurry contours, leukocytosis in the blood, increased ESR, eosinophilia, in the bronchial secret - pneumocysts.

2. In asthmatic bronchitis, there is an allergic history, subfebrile temperature, persistent cough with viscous sputum, mixed dyspnea, boxed percussion sound above the lung fields and weakened breathing, small and medium bubbling wet rales, moderate leukocytosis and eosinophilia in the blood. ESR is within the normal range.

3. Foreign bodies of the respiratory tract cause a sudden development of an attack of convulsive cough against the background of complete health, shortness of breath, which increases with the child's anxiety and disappears completely in a dream. X-ray changes in the form of unilateral emphysema or atelectasis, the absence of hematological changes, the appearance of granulations in the larynx or bronchial tree

4. With whooping cough, the onset is subtle, paroxysmal agonizing cough, puffy face, eyelids swollen, boxed percussion sound, intermittent dry and moist rales in the lungs, viscous sputum, on the x-ray, an increase in the transparency of the lung fields, flattening of the domes of the diaphragm, increased lung pattern, expansion of the roots in in the form of radial lines, leukocytosis in the blood, the predominance of lymphocytes.

CLINICAL DIAGNOSIS

Based

1. Complaints of the mother of the child - fever up to 37.5 C, cough, runny nose, hoarseness.

2. Objective data: - dry cough

Percussion sound with box tone

Harsh breathing, dry whistling rales.

3. Instrumental examination data - increased lung pattern, root juiciness, marginal emphysema

4. Laboratory data - an increase in ESR, a decrease in the number of red blood cells, lymphocytosis

5. Growth scores - 33.5% overweight

6. Assessment of the general condition - pallor, pastosity, decreased tissue turgor

7. Information about other diseases - PEP

made a clinical diagnosis:

Primary: SARS, obstructive bronchitis of moderate severity

Associated Zab .: paratrophy 3 tbsp., PEP, hyperexcitability syndrome

ETIOLOGY.

Etiology of the underlying disease.

Bronchitis is a complication of SARS

The causative agent of SARS can be

Influenza viruses (serotypes A and B)

Parainfluenza viruses 4 serotypes

Adenoviruses (more than 30 serotypes)

Rhinoviruses

Enteroviruses

Respiratory syncytial viruses.

Associations of viruses

Etiology of concomitant disease.

In this child, paratrophy has a mixed etiology and is postnatal dystrophy, which is caused by exogenous factors:

Alimentary - unbalanced diet

Infectious - intestinal infection

Dysbacteriosis

Anemia and gestosis of the 2nd half of the pregnancy of the mother of the child are of some importance.

PATHOGENESIS

The pathogenesis of the underlying disease:

Reproduction of viruses in sensitive cells Viremia Damage to the respiratory organs Regression of the pathological process

Associated disease pathogen:

PEP Changes in the central nervous system Unstable secretion of the gastrointestinal tract Violation of the humoral and endocrine regulation of metabolic processes Metabolic acidosis Decreased body resistance

TREATMENT

1. Individual mode

2. Nutrition.

Calculation of the need for milk for a child of five months:

1) 1/7 body weight (9800g) = 1400 ml

2) according to Shkarin's formula: = 800+5*(N-2), where N is a month = 950ml

3) according to nutritional standards - for five months - 900-1000 ml

Thus, the daily requirement of a child for milk is ~ 1l

The child is on mixed feeding

Sample menu:

06.00 - breast milk or formula 200 g.

10.00 - milk buckwheat or any "gray" porridge 200 g.

14.00 - vegetable puree 200 g.

18.00 - breast milk / formula 200 g, fruit juice - 50 g.

22.00 - breast milk / formula 200 g.

3. Etiotropic therapy

Rp: Cephazolini 0.25

D.t.d. N 10 in amp

S. i / m 2 r / d for 5 days

Rp: Oxacillini 300000ME

D.t.d. N30 in amp

S. Dissolve the contents of the ampoule in sterile water for injection, inject intramuscularly 3 times a day at 300,000 IU

4. Pathogenetic therapy

Rep: Sol. Euphyllini 1%-50ml

D.S take 1 tsp orally. 3 r/d

Rp: Sol Suprastini 2%-0.3ml

D.S. i/m 1 r/d

Rp: “Berodualum” 20?0 ml

D.S. inhalations: 10 drops 3 r / d

Rp: Massage on the chest area No. 2 for 10 minutes daily

4. Symptomatic therapy

Rp. M-rae Paracetamoli 200.0 ml

Rp. M-rae Bromhexini 200.0 ml

D.S. Inside, 1 tsp. 3 r/d

TEMPERATURE SHEET.

14.02.03 Complaints of cough, runny nose, loose stools. Breathing through the nose is free. Above the lungs are single dry rales. RR 40 per min. Heart tones are rhythmic, clear. Pulse 130 per minute. The abdomen is soft. painless. t-

17.02.03 Complaints of cough, runny nose. Breathing through the nose is free. Above the lungs are single dry rales. RR 36 per min. Heart tones are rhythmic, clear. Pulse 130 per minute. The abdomen is soft. painless. t - The chair returned to normal, Treatment is receiving.

19.02.03 Complaints of cough, runny nose. Breathing through the nose is free. Above the lungs are single dry rales. RR 38 per min. Heart tones are rhythmic, clear. Pulse 125 per minute. The abdomen is soft. painless. t - Treatment is received.

EXECUTIVE EPICRISIS.

Buryachenko Anastasia Dmitrievna was admitted to the 3rd children's department of the BSMU clinic on February 10, 2003 with complaints of fever, runny nose, cough.

An examination was carried out - physical, laboratory, instrumental, and the diagnosis was made: Main: SARS, obstructive bronchitis of moderate severity

Associated Zab .: paratrophy 3 tbsp., PEP, hyperexcitability syndrome

Conducted antiviral, pathogenetic and symptomatic therapy. Physiotherapy procedures. Nutrition according to age with correction for vitamins and trace elements.

Discharged 21.02.03 in a state of improvement under the supervision of the local pediatrician.

The prognosis of the disease for life and in relation to recovery is favorable.

1. Rational nutrition

2. Air baths at 20 C, airing 4-5 times for 10-15 minutes in the presence of a child.

Walks at t not lower than -12 C from 15 minutes to 2 hours 2 times a day.

3. Sunbathing

4. Water procedures.

5. Massage

Used Books:

1. Propaedeutics of childhood diseases, A.V. Mazurin, Moscow, “Medicine”, 1985

2. Children's diseases, A.A. Isaeva, Moscow, “Medicine”, 1986

respiratory distress syndrome newborn

Gender Female

Age - 14 days

Date of birth - 10/17/13

Date of receipt - 10/17/13

Parents: mother - 33 years old, father - 35 years old

Complaints upon admission to the clinic: none.

General condition of the child: moderate. Body temperature 36.4o C. Position in bed "frog posture", spontaneous motor activity is minimal.

Provisional diagnosis: Respiratory distress syndrome of the newborn. Cerebral ischemia III - IV degree. Syndrome of oppression. Syndrome of muscular hypotension. Prematurity I degree.

Justification of the preliminary diagnosis

The diagnosis was made on the basis of: complaints - loss of appetite, lethargy, anxiety;

medical history - at birth diagnosed with Respiratory Distress Syndrome of the Newborn. Cerebral ischemia II degree. Syndrome of oppression. Prematurity I degree. Risk group for VCI. The condition developed against the background of the pathological course of pregnancy (Chronic fetal hypoxia, uterine fibroids, CMV, HSV, threatened miscarriage at 10 weeks, toxicosis up to 16 weeks, from 22 weeks - Uteroplacental insufficiency). In agreement with the head of the department, she was transferred to the NICU. The condition stabilized on the background of the treatment.

Differential series It is necessary to carry out differential diagnostics with pneumonia, anomalies in the development of the lungs and heart, traumatic brain injury, diaphragmatic hernia.

Additional examination plan

3. Biochemical blood test: total bilirubin, direct bilirubin, indirect bilirubin, AST, ALT, potassium, sodium, calcium, magnesium, total protein, urea, creatinine, glucose.

6. Plain radiography of the chest and abdomen

7. Neurosonography

8. Consultation with an ophthalmologist

9. Neurologist's consultation

10. Consultation with a cardiologist

Treatment plan

General mode

Child's diet. The child is breastfed. The daily amount of food for a newborn:

2622 x 120 = 315 kcal / day;

(315 kcal x 1 l) / 700 kcal = 0.45 l / day;

0.45 l / day / 7 times = 0.06 l = 60 ml of milk per feeding

The daily requirement for proteins is 5.8 g, fats 17 g, carbohydrates 34 g.

Feeding regimen: breast milk 60 ml every 3 hours with a night break lasting 6 hours.

Medical therapy

Means that normalize the intestinal microflora

Rp.: Pulv. Lactobacterini № 30

D.S. 2 doses 2 times a day orally.

Hepatoprotectors, choleretic agents

Rp.: Susp. Ursofalk 250 ml

D.S. 1.5 ml 1 time per day orally.

Metabolic agent that stimulates metabolic processes

Rp.: Sol. Elcar 25ml

D.S. 6 drops 2 times a day inside.

Broad spectrum antibiotic

Rp.: Ceftriaxoni 1.0 №10

D.S. 0.12 g 1 time per day / m.

Nootropic

Rp.: Sol. Piracetami 20% - 5 ml

D.S. 0.5 ml 1 time per day i.v.

Angioprotectors and microcirculation correctors

Rp.: Sol. Pentoxyphillini 2% - 5 ml

D.S. 0.2 ml 1 time per day i.v.

Correction of the electrolyte composition of the blood

Rp.: Sol. Glucozi 10% - 100 ml

Sol. Kalii chloridi 4% - 7 ml

Sol. Magnesium sulfatis 25% - 2 ml

Rp.: Sol. Glucozi 7.5% - 50 ml

Sol. Calcii gluconatis 10% - 2 ml

M.D.S. 1 time per day in / in at a rate of 10 ml / hour.

observation diary

Complaints of poor appetite, lethargy, drowsiness.

General condition of the child: moderate. Body temperature 36.8o C. Position in bed "frog posture", spontaneous motor activity is minimal. The reaction to the inspection is sluggish. Pupillary reaction to light is alive, corneal, conjunctival, orbiculopalpebral reflexes are alive. Fixes a moving object with a glance. The swallowing reflex is preserved. Tendon reflexes are weakened D = S. The volume of passive movements in the limbs is increased. The protective reflex is preserved. Robinson's grasp reflex is weakened. The Moro reflex is weakened. The Galant reflex is absent. Reflexes of support, automatic gait, crawling according to Bauer are absent. The Perez reflex is weakly positive. Sucking, search, proboscis reflexes, Babkin's reflex are positive. Babinsky's symptom is positive. The skin is marbled, subicteric, perioral, periorbital cyanosis. On palpation, the skin is moderately moist, elastic, warm. Mucous membranes are pink, clean, moist, without pathological elements. The sclera are subicteric, there are no injected vessels. In the lungs, puerile breathing over the entire surface of the lungs. Wheezing - absent. Respiratory rate 48 times per minute, arrhythmic, both halves of the chest participate symmetrically in the act of breathing, swelling of the wings of the nose, retraction of the sternum and retraction of the intercostal spaces during breathing are noted. Heart sounds are muffled, rhythmic. Volume 1 and 2 are the same. Noises: there is a short systolic murmur at the apex, it is not carried out. The pulse on the radial arteries is rhythmic, well filled, tense, symmetrical, the pulse rate is 130 beats/min. AD 75/30 mm. rt. Art. The abdomen is soft, painless, not swollen. The lower edge of the liver is sharp, smooth, elastic, painless, comes out from under the edge of the costal arch by 1.5 cm, the surface of the liver is smooth. The gallbladder is not palpable. Chair: Multiplicity - 4-5 times a day. The consistency is soft. Yellow color. An admixture of blood, greenery, mucus, no. Urination free, 20 - 22 times a day.

Patient K., 14 days old, was transferred to the emergency department from the NICU on February 24, 2012 for further examination and treatment. Translational diagnosis: Respiratory distress syndrome of the newborn. Cerebral ischemia III - IV degree. Syndrome of oppression. Syndrome of muscular hypotension. Prematurity I degree.

Complaints on the day of curation: loss of appetite, lethargy, anxiety.

Anamnesis of the disease - at birth diagnosed with Respiratory Distress Syndrome of the Newborn. Cerebral ischemia II degree. Syndrome of oppression. Prematurity I degree. Risk group for VCI. The condition developed against the background of the pathological course of pregnancy (Chronic fetal hypoxia, uterine fibroids, CMV, HSV, threatened miscarriage at 10 weeks, toxicosis up to 16 weeks, from 22 weeks - Uteroplacental insufficiency). In agreement with the head of the department, she was transferred to the NICU. The condition stabilized on the background of the treatment. For further examination and treatment, she was transferred to the OPNIID on 10/24/2013.

Against the background of the treatment, a positive trend in the patient's health status is noticeable, which is confirmed by the results of laboratory tests:

Date of issue: 12.11.

Approximately 10% of newborns worldwide are born prematurely. A baby is considered premature if he was born earlier than 37 weeks of gestation and has a birth weight below 2.5 kg. Of course, such children require special treatment and care. So, the case history: a premature baby is the topic of this article.

stress at birth.

By itself, the process of childbirth for a premature baby is an extremely difficult test, so doctors from different countries, if it is impossible to stop premature birth, tend to insist on a caesarean section. However, there is not always time and practical opportunity for this. In this case, they try to take the newborn baby as carefully and accurately as possible. Immediately after birth, a premature baby falls into the hands of a neonatologist for the timely detection of possible congenital anomalies and other problems. If during the examination the need for resuscitation is not revealed and intensive care is not required, the child is swaddled and placed in a special incubator (incubator). It maintains the optimum temperature and humidity.

After the birth.

After discharge from the maternity hospital, a premature baby still needs special care. Everyone understands that breastfeeding is the best option for a newborn. In the case of premature babies, it is simply vital. Mother's milk increases the child's immunity, supplies a number of optimal nutrients, essential vitamins and microelements to his body. Physical contact during breastfeeding is also important - it relieves many neurological problems. Therefore, children who were born prematurely must be breastfed at the first request. In cases where the baby does not have enough strength to suckle the breast, you need to express milk and give it from a bottle.

Basic care.

A premature baby is much more at risk of infectious diseases. That is why when caring for him, you need to pay more attention to hygiene. All baby clothes, diapers must be ironed with a hot iron. Nipples and bottles must be boiled. Bathe the child in warm boiled water. In the room where the child is located, the temperature should be maintained at 22-23 degrees. It is extremely important to avoid sudden changes in temperature and drafts.

Massage.

The baby really needs physical contact with his mother, especially if he receives milk only from a bottle. You need to try more often to take the child in your arms, caress, hug him to you. A light massage is also useful for the baby. For children born weighing less than 1.5 kg, massage should begin no earlier than six months after birth. If the child weighed more than 2 kg at birth, then massage can be carried out from the second month of life. The massage session should not be long (1-2 minutes), and the movements should be made lighter than for ordinary children.

From the first days of life, if there is no serious illness, a premature baby needs regular laying out on the tummy. This stimulates his emotional and physical development, strengthens the main muscle groups (abdomen, back, limbs). Spread on the baby's tummy only before feeding and no more than 2-3 minutes. For starters, it is enough to carry out this procedure once a day.

Despite the fact that the medical history of a premature baby is not easy, it should by no means be perceived as inferior. Increased anxiety for the future of the baby is understandable, but not too justified. Extra complexes will not benefit the baby, because children very subtly feel the mood of their parents. Their concern and constant anxiety can negatively affect the psychological mood of the baby. With simple adherence to the recommendations of the pediatrician, attention, love and caring parental attitude, a child born prematurely grows and develops normally. By the age of 2-3 years, a premature baby with proper care is no different from their peers.

Ministry of General and Vocational Education of the Russian Federation

FSBEI HPE "Mordovia State University. N.P. Ogareva

medical institute

Department of Pediatrics

Disease history

Completed by: student 406 "B" group

otd. "Medicine"

Checked by: candidate of medical sciences,

Associate Professor, Department of Pediatrics

Saransk - 2012

Passport data

Gender Female

Age - 14 days

Date of birth - 17.02.12

Date of receipt - 17.02.12

Parents: mother - Nadezhda, 33 years old, father - Valery, 35 years old

Curation date: 03/02/12
Provisional diagnosis: Respiratory distress syndrome of the newborn. Cerebral ischemia III - IV degree. Syndrome of oppression. Syndrome of muscular hypotension. Prematurity I degree.
Clinical diagnosis: Respiratory distress syndrome of newborns. Cerebral ischemia II degree. Syndrome of oppression. Prematurity I degree. Disadaptation syndrome of the cardiovascular system of posthypoxic genesis.

Complaints upon admission to the clinic: none.

Complaints on the day of curation: loss of appetite, lethargy, anxiety.
Anamnesismorbi:

At birth, diagnosed with Respiratory Distress Syndrome of the Newborn. Cerebral ischemia II degree. Syndrome of oppression. Prematurity I degree. Risk group for VCI. The condition developed against the background of the pathological course of pregnancy (Chronic fetal hypoxia, uterine fibroids, CMV, HSV, threatened miscarriage at 10 weeks, toxicosis up to 16 weeks, from 22 weeks Uteroplacental insufficiency). In agreement with the head of the department, she was transferred to the NICU. Therapy: mechanical ventilation for 6 days, oxygen therapy for 1 day, ampicillin No. 8, amikacin No. 7, infusion therapy with electrolytes, cardiotonic drugs (dopamine, dobutamine). The condition has stabilized. On February 24, 2012, she was transferred to the OPNIID for further examination and treatment. Diagnosis during transfer: Respiratory distress syndrome of newborns. Cerebral ischemia III - IV degree. Syndrome of oppression. Syndrome of muscular hypotension. Prematurity I degree. Therapy: from February 17, 2012, ampicillin 130 mg intramuscularly 2 times a day; potassium chloride 4% - 7 ml + magnesium sulfate 25% - 2 ml intravenously at a rate of 10 ml / h), from 24.02.2012 lactobacterin 5 doses 2 times a day inside, from 27.02.2012 ursofalk 1.5 ml 1 once a day. On the background of treatment, there is a positive trend.
Anamnesisvitae:

Was born from the third pregnancy. In total, the mother has three pregnancies. The first 2 pregnancies were uneventful. The first birth in 2001, the second - in 2006. They ran fine. The third pregnancy proceeded against the background of Chronic fetal hypoxia, uterine fibroids, CMV, HSV. Threat of abortion at week 10, toxicosis up to week 16, from week 22 - Uteroplacental insufficiency. Material and living conditions during pregnancy are satisfactory, nutrition is regular, rational, in sufficient quantity.

Delivery was made at 37 weeks in the Russian Orthodox Church by caesarean section. Amniotic fluid is light, head presentation.

The condition at birth is severe due to the presence of symptoms of respiratory failure and cerebral ischemia against the background of immaturity and prematurity. Birth weight 2515 g, height 46 cm, head circumference 32 cm, chest circumference 31 cm, Apgar score 7/7 points. She screamed immediately, a squeaky cry, groans, a flexor posture. The skin is pink, pastosity of soft tissues, abundant primordial lubrication, white, large fontanelle 1.5 x 1.5 cm, not tense, muscle tone is lowered, hyporeflexia. The umbilical cord fell off for a day, the healing of the umbilical wound. Physiological weight loss of 150 g on the 5th day of life. Jaundice appeared on the 3rd day of life (subicteric skin and sclera) and persisted until the curation (subicteric sclera). The first application to the chest on the 7th day (the first 6 days were mechanical ventilation).

Feeding is natural. The feeding schedule is free. Appetite is good. Defecation 5-6 times a day, yellow stools.

Fixes the gaze on a moving object from the 10th day of life. Neuropsychic development corresponds to age.

At birth, diagnosed with Respiratory Distress Syndrome of the Newborn. Cerebral ischemia II degree. Syndrome of oppression. Prematurity I degree. Risk group for VCI.

Vaccination against hepatitis B and BCG-M is a medical challenge.

Family history. Mother - Kizhaeva Nadezhda Pavlovna, 33 years old, before the conception of the child often had respiratory diseases, was repeatedly hospitalized, no bad habits. Contact with obvious mutagens denies. Father - Kizhaev Valery Nikolaevich, had no bad habits for 35 years, there were no contacts with mutagens, acute respiratory infections, tonsillitis, pneumonia. There were no signs of chronic and genetic diseases in the parents. There are two children in the family, 11 and 6 years old. The children are healthy.

Living conditions are satisfactory. There were no contacts with infectious patients in the last 3 weeks.

Statuspraesens

General condition of the child: moderate. Body temperature 36.4 o C. Position in bed "frog posture", spontaneous motor activity is minimal.
Nervous system. The reaction to the inspection is sluggish. Nasolabial folds are symmetrical. Pupillary reaction to light is alive, corneal, conjunctival, orbiculopalpebral reflexes are alive. Fixes a moving object with a glance. The swallowing reflex is preserved. Tendon reflexes are weakened D = S. The volume of passive movements in the limbs is increased. The protective reflex is preserved. Robinson's grasp reflex is weakened. The Moro reflex is weakened. The Galant reflex is absent. Reflexes of support, automatic gait, crawling according to Bauer are absent. The Perez reflex is weakly positive. Sucking, search, proboscis reflexes, Babkin's reflex are positive. Babinsky's symptom is positive.
Physical development. centile method.

Sum of corridors = 5. Difference between corridors = 1.

Conclusion: microsomatotype, harmonious development.
Assessment of physical development by empirical formulas

The level of physical development is average, the child is developed harmoniously.
Assessment of physical development by indices.

Calf circumference - 7.5 cm

Thigh circumference - 10.5 cm

Shoulder circumference - 7.5 cm
Chulitskaya fatness index \u003d 3 * OP + OB + OG - height \u003d 3 * 7.5 + 10.5 + 7.5 - height \u003d -5.5 (malnutrition of the child)

Erisman index \u003d OG - P / 2 \u003d 31 - 46/2 \u003d 8 (normal)

Mass-height index of Verweck \u003d P, cm / (2 * B, kg + OG, cm) \u003d 46 / (2 * 2.622 + 31) \u003d 1.27 (moderate dolichomorphia)

Quetelet index \u003d B, kg / P 2, m \u003d 2.622 / 0.46 2 \u003d 12.3
Study of organs and systems.

The skin is marbled, subicteric, perioral, periorbital cyanosis. On palpation, the skin is moderately moist, elastic, warm. Hair fluffy, soft. Nails are oval, pink, without pathological changes, reach the fingertips.

Mucous membranes are pink, clean, moist, without pathological elements.

The sclera are subicteric, there are no injected vessels.

Subcutaneous fat development is moderate. The distribution is even. Edema is absent. Tissue turgor is normal.

Lymph nodes are not enlarged, painless.
Muscles. The degree of development corresponds to age, development is symmetrical. Tone - lowered. Pain on palpation and movement is absent.
Bone system. The head is rounded, the size corresponds to age. The palpebral fissures, nasolabial folds, auricles are symmetrical. The large fontanel is 1.5 x 1.5 cm, the small fontanel is not palpable, there are no deformities. Teeth are missing. The upper and lower limbs are developed symmetrically, painless on palpation. The joints are without deformity and defiguration, the range of motion is full, there is no pain during active and passive movements. The spine is located in the midline, there are no physiological and pathological bends.
Respiratory system. The shape of the chest is cylindrical, symmetrical, the width of the intercostal spaces is moderate. The shoulder blades fit snugly against the chest. The chest is flattened in the anterior-posterior direction. Chest deformities are absent. Thickening of the ribs on the border of the bone and cartilaginous parts is not detected. Nasal breathing. The type of breathing is mixed. Respiratory rate 48 times per minute, arrhythmic, both halves of the chest are symmetrically involved in the act of breathing. There is no shortness of breath. On palpation, the chest is elastic, painless. Breathing is carried out through all lung fields, weakened, retraction of the sternum and retraction of the intercostal spaces during breathing. Percussion sound - pulmonary.

index	On right	Left
Upper bounds	not defined	not defined
Lower bounds
l. parasternalis	upper edge of the 6th rib
by l. medioclavicularis	lower edge of the 6th rib
by l. axillaris anterior	7 rib	7 rib
by l. axillaris media	8 rib	8 rib
l. axillaris posterior	9 rib	9 rib
by l. scapuiaris	10 rib	10 rib
by l. paravertebralis		at the level of the spinous process of the 11th thoracic vertebra

The boundaries of the lungs - correspond to the age norm. The mobility of the lung edges is 1 cm on both sides. Auscultation: Breathing - puerile over the entire surface of the lungs. Wheezing - absent. Noise of friction of the pleura - not determined.
The cardiovascular system. Pathological pulsation of arteries and veins in the neck is not determined. The region of the heart is not changed, pathological pulsation in the region of the heart, the epigastrium is not revealed. Symptom "cat's purr", cardiac "hump", in the region of the heart are not defined. The apical impulse of moderate strength, resistant, is localized in the 5th intercostal space 1 cm outward from the left mid-clavicular line. The pulse on the radial arteries is rhythmic, well filled, tense, symmetrical, the pulse rate is 130 beats/min. There is no cardiac impulse on palpation of the heart.

Limits of relative cardiac dullness:

Auscultation:

Heart sounds are muffled, rhythmic. Volume 1 and 2 are the same. There is no split or split. There is a short systolic murmur at the apex, it is not carried out. Has a functional character. Pathological noises on the vessels are not auscultated. AD 75/30 mm. rt. Art.
The digestive system. Lips are pale pink. Mouth: enanthema - absent. The color of the mucous membranes is pale pink, there are no ulcers, there are no hemorrhages, the humidity is normal. Vomiting is absent. Tongue: pink, no plaque, moist, the pattern is weakly expressed. Deviation and tremor of the tongue is not observed. Throat: the color of the mucosa is pale pink. The salivary glands are not enlarged. Appetite saved. Belly: The shape is not changed, symmetrical, does not sink, is not swollen. Peristalsis is not visible. Participates in respiration. Ascites - absent. Percussion sound - tympathic. Tension of the abdominal wall, pain were not detected. The divergence of the rectus abdominis muscles is absent. Deep: the sigmoid colon is palpable in the form of a movable elastic cord, 1–2 cm in diameter, painless on palpation, not rumbling; in the form of a movable vertically located strand with a diameter of 2 cm, moderate density, painless, not rumbling; the ascending colon is palpated in the form of a movable vertically located elastic band, 2 cm in diameter, painless, not rumbling. The transverse colon is palpated in the form of a movable elastic band, painless on palpation, not rumbling, 2 cm in diameter. The stomach could not be palpated due to the child's anxiety. Sounds of intestinal peristalsis of moderate intensity are heard. The area of ​​the right hypochondrium is unchanged. The lower edge of the liver is sharp, smooth, elastic, painless, comes out from under the edge of the costal arch by 1.5 cm, the surface of the liver is smooth. The gallbladder is not palpable. Stool: Multiplicity - 4-5 times a day. The consistency is soft. Yellow color. An admixture of blood, greenery, mucus, no.
Hematopoietic organs. Groups of lymph nodes are palpated: occipital, cervical, submandibular. By consistency, all groups of lymph nodes are soft, elastic. Lymph nodes are painless, not soldered to the skin, there are no scars. The spleen is not palpable. Percussion dimensions: 5 x 3 cm.
Urogenital organs. A protrusion above the pubis is absent. The lumbar region is not visually changed. The kidneys are not palpated. The bladder is not palpable. Urination - painless, 20 - 22 times a day. Diuresis corresponds to age. The color of urine is yellow. Portions of urine are normal. The development of the genital organs corresponds to age. The testicles are descended into the scrotum.