anna cherkosova
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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