PEOPLE’S FRIENDSHIP UNIVERSITY OF RUSSIA

FACULTY OF MEDICINE

DEPARTMENT OF PEDIATRICS

HEAD OF DEPARTMENT- Проф. КУЗМЕНКО Л.Г.

STATUS PRESENCE

NAME OF PATIENT: ПЕТРОВИЧЕВА ТАТЬЯНАСЕРГЕЕВНА

Преподаватель:Асс.Доцент КУТАФИН Ю. Ф.

Сurator- Deepankar Srigyan

Group- ML 511

MOSCOW 2008

Full name of Patient: Petrovicheva Tatyana Sergeevna

Age (date of birth): 13 yrs (02-04-1995)

Nationality: Russian

Date of admission: 04-11-2008 at 11 AM

Date of starting of curation: 12-11-2008 at 12AM

Clinical Diagnosis: Congenital Heart Defect

STATUS PRESENCE

General state: satisfactory

Position of the patient: active

Body Constitution:

Parameters: In normal- Of patient-

Body height 153 cm. 163 cm.

Body weight 34-36 kg. 38 kg.

Circumference of head 55 cm. 55 cm.

Circumference of chest 69 cm. 65 cm.

Physique(body build): asthenic.

Skin: dry, pale-pink, with itching shade on upper & lower limbs.

Subtaneous fatty layer: moderate & equal development.

Turgor of the tissues: normal satisfactory; no oedema; normal elasticity of skin.

Lymphatic nodes: mandibular lymph nodes are palpable, 4-6 in numbers, with low consistency & free mobility, low sensibility.

Muscular system: moderate development, tonus & force normal.

Skeletal system:

skull well developed,fundicular constitution:Size- 55 cm.,skull sutures stabilized. Thorax: closer to cylindrical form, deformed at xiphoid process of sternum. Vertebral column: presence of scoliosis at thoracic vertebral column. Extremities: unchanged, left side shoulder down. Joints: unchanged, free movements of joints.

Respiratory system:

Type of respiration: thoracic; nasal respiration free, no discharge from nose. Respiratory rate- 20 per min.

Voice: clear, Cough: dry, Respiration: equal but difficult(dyspnoea) on physical heavy work. Vocal tactile fremitus not changed; Bronchophonia(vocal resonance) not changed.

Lungs:On comparative percussion- pulmonary/clear percussion note over the entire surface.

Lower borders of lungs : In Normal-

Lines Right Left

Midclavicular line 6th rib Lower border of left lung along the midclavicular line remarkable away from sternum at height of 4th rib and sharply goes down.

Mid-axillary line 8th rib 9th rib

Scapular line 9th -10th rib 10th rib

Paravertebral line At the level of spinous process of 11th thoracic vertebrae.

At the level of spinous process of 11th thoracic vertebrae.

Lower borders of lungs : In Patient-

Lines Right Left

Midclavicular line 6th rib Lower border of left lung along the midclavicular line remarkable away from sternum at height of 4th rib and sharply goes down.

Mid-axillary line 8th rib 9th rib

Scapular line 10th rib 10th rib

Paravertebral line At the level of spinous process of 11th thoracic vertebrae.

At the level of spinous process of 11th thoracic vertebrae.

Mobility of lung’s borders: 0.5-1.0 cm.

Character of breathing: vesicular breathing, dry rales.

Circulatory organs:

Visible chest deformity at lower sternal region, postoperative scars present; Vessels of neck are not visible but jugular veins are palpable. Apex beat heard at 5th intercostal space 0.5 cm. inside from midclavicular line.

Borders of absolute dullness of heart:

Borders: In normal- In patient-

Upper 4th rib 4th rib

Left Between midclavicular & parasternal line, nearer to parasternal line.

Between midclavicular & parasternal line.

Right Left border of sternum. Left border of sternum.

Borders of relative dullness of heart:

Borders: In normal- In patient-

Upper 3rd rib 3rd rib

Left 0.5 cm inside from left midclavicular line.

On midclavicular line.

Right Right border of sternum Right border of sternum

Apex beat 0.5 cm inside from left midclavicular line at 5th intercostal space.

On midclavicular line at 5th intercostal space.

Tones: noisy and rhythmic.

Sound: systolic murmurs at apex on midclavicular line at 5th intercostal space.

Pulse: rhythmic, frequent, uniform. Pulse rate- 90/min.

Arterial blood pressure: 110/70 mmhg.

Digestive organs:

Lips: pink, moist; Tongue: clean, moist. Buccal mucosa and gums are healthy; Oro-nasopharynx is clear, tonsils are normal; Number of teeth- 28 are permanent,clean & healthy. Abdomen symmetrical, oval shaped,scars absent. State around the umbilical region: hernias absent. Appetite normal, eating 3-4 times in a day. Liver is palpable 1 cm below the costal margin, dense, smooth, absence gravity of pain.Spleen is not palpable. Stool: frequency- 1 time in a day, formed, soft consistency, brown colour, without tenderness of defaecation, condition of rectum is good.

Urogenital system:

Type of urinary passage- free, 5-6 times in a day.Pasternsky's symptom absent. Urine: light yellow color, full transparent; Specific gravity of urine- 1020.

Development of sex organs: SMR Stage(Sexual maturity rating)- 3, Breast and areola enlarged,no contour separation; pubic hairs appeared and secondary sexual signs are well visible.

Neurological and endocrine system:

Sense organs: eyes- good visual acuity, good condition of conjunctiva and pupil. Ears- good audition, the condition of pinna & external meatus is good. Conciousness clear, good intellect, good mood & clear speech.Sensitivity of tactile, painful and temperature is normal. Pathological reflexes (hyperkinesias, tremors) are absent.

Condition of endocrinal glands is good.

THE LITERATURE USED:

1. Essential pediatrics,6th edition by O.P.Ghai, Piyush Gupta and V.K.Paul, CBS Publishers, India,2008.2. Детские Болезни:Учебник,часть-1, . ., . .,ТюринНА Кузьменко ЛГ М.:Изд-во РУДН,2004.-610 с.3. Class materials given by Асс. . . Доцент КУТАФИН Ю Ф And

. . , КонтемироваМГ РУДН.4. Tsepova E.L. Recording patient’s case report (information book for the third year foreign medical students). – Smolensk: SSMA, 2004. – 58 p.5. Macleod’s Clinical Examination // Edited by John F. Munro, Ian W. Campbell / Tenth edition. – 2000. – 312 p.