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Patients profile

Name : cherkosova anna

Age : 7

Sex : femaleDOB : 23rd July 2000

Address : Moscw

DOA : 7th Nov 2007

Bed : palata 4

Weight : 23.15 kg

Height : 123.5cm

Complaints on admission

She complains about difficult breathing thru nose, presents of skin rash and also hoarseness of voice

Anamnesis Vitae

1. characteristic of newborn

full term baby, normal weight and height. She was breast fed till 4 th months. Then she was continue

with the infant formula.

Toward the 1st year, her teeth corresponded to her age. First word corresponded to her age.

Vaccination of her is up to date. BCG vaccination. Mantaux reaction at 13th

May 2007, around 1.1cm.

Mother : vaaricose vein disease with allergic reaction

Dad : allergic rhinitis, allergic to dust and pollens

Brother : allergic to pollens

Grandpa (mum) : pancreatitis

Grandma (mum) : healthy

Grandpa (dad) : bronchial asthma

Grandma (dad): arterial hypertension

Annas house has two cats. Synthetic blankets and pillow.

Anamnesis Morbi

1 yr old : atopic dermatitis and ARVI

2 and half yrs old : obstructive bronchitis

btw 3-6 yrs old: exacerbation of ARVI that limited her physical activity, more intense dry cough and

diffulcuty in breathing.

In 2005 : she had left sided pneumonia11th May 2007 : cough, difficulty in breathing and harsh breathing. She was treated and her

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condition was improved.

8th June 2007 : she went for allergic consultation. Functional spirography was performed.

Histamine test was done and cause bronchoconstriction. She was diagnosed with atopic bronchial

asthma, mild persistent type on date of admission. They recommended her to take sodium

cromoglycate ( intal ) in form of inhaler, last for 3 months. If there is no effect, take beclomethasone200 microgram / day. She was not compliant to therapy.

She had an exacerbation and was given ipratropium bromide + fenoterol thru nebulizer.

Sept 2007, she took intal ( sodium cromoglycate ) and her condition improved

In october, another episode of ARVI, conditioin worsen, she had difficulty in breathing and

wheezing.

7th of Nov 2007, she was admitted to this paediatric hospital

Status Prasens ( on admission )

General condition : satisfactory

Nervous system : conscious, responsive, well orientated in time and space. Attention and

memory is good, intellectual development corresponds to her age, speech is clear and proper, sleep

is not disturbed, no abnomalities of cranial nerves. Abdomen and deep reflex are preserve. No

meningeal symptoms. For inspection, no pathological changes of eyes and ears.

Physical development

Weigh 23.15 kg, height 123.5 cm ( calculation: )

Skin : pale skin and mucous membrane. Physiological moisture in place like armpit and palm, and

physiological dryness in place like elbow and knee. No visible scars. Normal hair growth at scalp.

Normal elasticity and normal turgor. No oedema, skin temperature warm.

Subcutaneus fat : moderately develolped.

Lymph nodes : submandible, inguinal and axillary lymph node are palpable without any

significat enlargement, painless on palpation. All other lymph nodes are not palypable. Tonsil are

significantly enlarge.

Musculoskeleta system : normal tone, painless during palpation, normal nuscle strength. Joints

movement without limitation. Physiological lardosis of cervical vertebral. No scolliosis is observed.

Normal form of head ( round ) no softening or deformaties of cranial bone and fontanella.

Cylindrical chest form. Extrimities are normal without other pathology

Respiratory systemImpaired nasal breathing. Breath thru the mouth, respiratory rate 19 /min. no coughing and dyspnea.

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Thoroacic respiration. Absent of nasal bleeding, absent of secretion. Hoarseness of voice.

Cylindrical chest constitution. No deformities of chest. Palpatioin : no changes on chest resistent, no

pain on palpation, normal elasticity, symmetrical vocal fremitus. Percussion ( comparative ) : band-

box sound on both sides. Topographical percussion ( ) mobility of lower border () ausculation : no

crepitation, no wheezing, no rales.

Bld circulatory system

Symmetrical pulsation of all peripheral pulse ( temporal, radial, carotid, femoral, dorsalis pedis and

brachial arteries )

Radial pulse : 88 bpm ( L=R )

BP : 90/50 mmHg

Palpation : heart apex at left mid clavicular line at 5 th intercostsal space. Percussion : heart border

corresponds to age. ( L, R n upper border )

Auscultation : clear heart sound, slight systolic murmurs

GIT system

Good appetite, no nausea and vomitting, clean, moist with no white coating on tongue, form stool

with normal colour. lips are rossy in colour. oral cavity and gums are clean. Mucous membrane pale

rossy colour. pharynx : tonsil are slightly enlarge. Salivary gland not enlarged, no pain, no changesof skin around the glands. Scar absent on abdomen. Skin fold 2 cm. ascites absent. Superficial

palpation : abd soft and painless on palpation. Deep palpation : painless

Liver : smooth surface, palpable at the margin of costal arch. Spleen not palpable. Percussion :

tympanic sound.

Size of liver base on Kurloff : 9 cm R midclavicular line, sternal line 8 cm and oblique size along

costal arch 7cm.

spleen percussion : length 7 cm ; width is 4 cm

Urogenital System

Urination of normal frequency, free and painless. Palpation at kidney area painless. Kidney not

palpable.

Preliminary diagnosis: adenoid and atopic bronchial asthma

Plan of investigation:

Complete bld count

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Biochem analysis of bld

Immunological test

Coprolgram

Hep B & c test

CXRECG

Ultrasound of heart and internal organs

Stool analysis

Spirogram with ventolin / salbutamol

Spirogram with physical exercise

ENT specialist

Results of

Stool analysis : helminths eggs are present. Otherwise non - significants.

CXR : moderate air in lungs ( emphysema-like ), no infiltration, mediastinum is insignificant.

ENT specialists report : allergic rhinitis was diagnoses. It is persistent seasonal exacerbation. X-ray

on sinuses are recommended. Sodium cromoglycate intranasally was prescribed for 1.5 months.

Diagnosis : atopic form bronchial asthma with mild persistent