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PASSPORT DATA

Surname, Name : ISHCHENKO ZOKHORIYE


Age : 11 months
Date of birth : 06-03-2015
Gender : male
Nationality : Ukrainian
Height : 70cm
Weight : 9.5 kg
Address : IVANO-FRANKIVSK
Date of hospitalization : 21-02-2016
Date of discharge :
Primary diagnosis : HYPERTHERMIA SYNDROME
Diagnosis after hospitalization : HYPERTHERMIA SYNDROME
Diagnosis on treatment : SEVERE ACUTE RESPIRATORY SYNDROME
Result of treatment : SATISFACTORY

COMPLAINTS
I) DURING ADMISSION
high temperature, conjunctivitis, sore throat, stomach ache,
vomiting
II) DURING CURATION
Intoxication, vomiting, high temperature

ANEMNESIS OF DISEASES

The patient had temperature, sore throat , mother self treated her
baby. Then in the evening the baby had stomach ache. She went to
physiotherapist where she did the enema with absorptive medicine
also gave the suppositories of rectum ( VIBRIOCOLI + PARACETAMOL)
which worked as hemostatic antiviral. Baby also had physiological
tuberculosis on the 3rd - 4th day of going home, physiological jaundice.
patient had bronchitis too on 25-01-2016 for 1.5 weeks. Once the
patient got sputum too with the food.

ANEMNESIS OF LIFE
I)OBSTRETIC ANAMNESIS :
The patient was born with normal delivery of 13 hours in the
39 week of the pregnancy.
Also there was artificial stimulation of labour because she was
having weakness of uterine wall.

th

Patient had breast feeding for only one month after that the
mother started giving mixed feeding i.e. Breast milk as well as
heap organic food.
From 6th month the mother started giving the full artificial
feeding i.e.
The baby eats meat, soft cheese, banana, apple and also
drinks vegetables soup.
Prolong night patient drinks.
The patient has only 2 lower teeth which is not normal,
normally a 11 month baby should have 7 teeth.

II) PHYSICAL & PSYCHOMOTOR DEVELOPMENT OF THE CHILD :


After birth the patient's weight was 800 grams which is good and
now the patient is 11 months and is 9.5 kilograms.
Also patients height according to the age is satisfactory i.e. 70

cm in 11 months.
Rest physical and psychomotor development is normal.

III) BREAST FEEDING :


Patient had breast feeding for only one month after that the
mother started giving mixed feeding i.e. Breast milk as well as
heap organic food.
th
From 6 month the mother started giving the full artificial
feeding i.e.
The baby eats meat, soft cheese, banana, apple and also
drinks vegetables soup.
Prolong night patient drinks.

IV) VACCINATION :
Tuberculosis

V) DISEASE TILL DATE:


Intoxication
bronchitis
hyperthermia syndrome
physiological jaundice
conjunctivitis

VI) ALLERGIC ANAMNESIS :


not revealed yet
VII) HEREDITARY & FAMILY ANAMNESIS :

None
VIII) SOCIO ECONOMIC CONDITION : Satisfactory
EPIDEMIOLOGICAL ANAMNESIS :

SATUS PRAESENS OBJECTIVUS :


THE GENERAL CONDITION OF THE CHILD : Moderate
patient feels irritative
position on the bed is active.
Consciousness clear
sleep fine
appetite fine
ARTHROPOMETRICAL PARAMETERS :
Both height and weight are having good development.
Normostenic.
SKIN : The color of the skin is normal. No rash or scars are
identified. The hairs and nails are normal too.
MUCOUS MEMBRANE : The color of the mucous membrane is
normal but in the oropharyngeal region is hyperemic earlier as he was
having sore throat.
SUBCUTANEOUS LAYER : All is uniform no thickness, tissue turgor
or condensation.
MUSCULAR SYSTEM : Degree of development of muscle mass,

muscle development, strength are all normal. All the movements are
co-ordinated too.
BONE SYSTEM : All normal shape, size, thickness. No deformity in
any part of the body.
LYMPHATIC SYSTEM : After palpation no signs of swelling or
enlargement of any lymphatic nodules. Also the status of lymphatic
nodes of chest are normal too.
RESPIRATORY SYSTEM :
Frequency of respiratio : 50-60 breaths per minute
Rhythm : arrhythmic
Breathing types :
Nasal breathing : difficult
voice : wheeze
Cough : just once with food
Dyspnea : expiratory
Thorax : normal
Palpation :
Paining : no pain during touch
Resistance : minor decrease in resistance
Thickness of skin folds from both sides at the level of
scapula : ABSENT
Voice tremor : not revealed
Topographical percussion : normal
Comparative percussion : decrease in resonance
Auscultation : dry sonorous

CARDIOVASCULAR SYSTEM
There is no pathological pulsation in the neck.
On palpation, the apex beat is defined in 5th intercostal space on 1cm
inside from left mid clavicular lines. Symptom of "cats purr" is absent.

Percussion:
The borders of relative cardiac dullness:
Right border: at 4th intercostal space, 1cm outside from right edge of the
breastbone.
Upper border: at 3rd rib, beside left edge of the breastbone
Left border: at 5th intercostal space, 1cm inside from the mid clavicular
line.
The borders of absolute cardiac dullness:
Right border: at left edge of the breastbones in 4th intercostal space
Upper: at 3rd rib
Left border: at 1cm from border of relative cardiac dullness.
On auscultation:
The tone of heart is increased, rhythmic. Fissions tone of heart is absence.
The heart murmurs are not listened too. The pleural friction is absent. On
jugular veins, there are no murmurs.
Pulse: 70 beats/ min.
BP: 124/80

DIGESTIVE SYSTEM :
Inspection of mouth : hypermic mucosa of oropharyngeal region
Inspection of stomach :
form & size of abdomen : normal
divergence of recto- abdominal muscle : absent
expansion of frontal veins of belly : no
participation belly in breathing : yes
Percussion of abdomen : normal ( tympanic voice throughout the
abdominal region except liver with dull sound = normal )
Superficial palpation of abdomen : no tenderness of muscle, the
borders of the intestine are clear, smooth, no elevation or mass.
Spleen is not palpable. No pain during palpation.
On deep palpation there was no pain in the right upper
hypochondrium region, borders of the liver were smooth and clear.
Auscultation : no pathological sounds were heard.
Anal condition : normal

THE SYSTEM OF KIDNEY AND URINARY PATHS :


Examination : no appearance of painness
absence of renal edema
absence of any kind of pain in lumbar region and no
pathological mass
Palpation : no pain during palpation near kidney and along the
ureter.
Percussion : dull sound on the urinary bladder.
Pasternatskiy's symptom : negative
frequency of urination : normal ( absence of pain during urination)
Urine :
NERVOUS SYSTEM : normal, absence of any pathological symptoms
, absence of any kind of pathological reflexes.

ENDOCRINE SYSTEM : no disorder of growth


weight of the body is normal
thyroid gland : normal size & shape
sexual development : normal

PRELIMINARY DIAGNOSIS
Acute bronchitis

PLAN OF EXAMINATION
General blood test 22-02-2016
biochemical blood test 22-02-2016
urine test 22-02-2016
X-RAY 23-02-2016

microbial culture test 22-02-2016


functional test 22-02-2016
ECG 23-02-2016

GENERAL BLOOD TEST

Item

Value

NORM

Erythrocyte

3.9-4.7

hemoglobin

120- 140 g/dl

Color index

0.85 1.14

thrombocyte

4000 - 11000

leukocyte

4 to 9

neutrophil

40-75 %

eosinophil

1-6 %

basophil

0-2 %

lymphocyte

15-40 %

monocyte

2-10 %

ESR

8 to 15

CONCLUSION:

Urine Test
Item

Value

volume

100ml

Color

Light yellow

transparency

Transparent

Specific gravity

1.01

RBC

absent

protein

absent

Biochemical blood test


Item

Value

Norm

cholestrol

<200

LDL

<50

HDL

>60

triglyceride

<150

protein
glucose

3.3 to 5.5

AST

Up to 40

ALT

Up to 40

X_RAY: revealed localised infiltrative shadows on both lungs.


ECG: revealed slight tachycardia
Stool test: revealed amylorrhea. No helminth or any bacteria.
Microbial test : suspected presence of adeno virus ( conjunctivitis)

DIFFERENTIAL DIAGNOSIS :
Pneumonia
Asthma
Bronchiolitis
Rhino viral infection

Tuberculosis
Influenza

CLINICAL DIAGNOSIS :
SEVERE ACUTE RESPIRATORY SYNDROME complicated with
HYPERTHERMIA SYNDROME

ETIOLOGY & PATHOGENESIS OF THE DISEASES :


SARS is caused by a member of the coronavirus family of viruses (the
same family that can cause the common cold).
When someone with SARS coughs or sneezes, infected droplets spray
into the air. You can catch the SARS virus if you breathe in or touch
these particles. The SARS virus may live on hands, tissues, and other
surfaces for up to 6 hours in these droplets and up to 3 hours after
the droplets have dried.
While the spread of droplets through close contact caused most of
the early SARS cases, SARS might also spread by hands and other
objects the droplets has touched. Airborne transmission is a real
possibility in some cases. Live virus has even been found in the stool
of people with SARS, where it has been shown to live for up to 4 days.
The virus may be able to live for months or years when the
temperature is below freezing.
With other coronaviruses, becoming infected and then getting sick
again (re-infection) is common. This may also be the case with SARS.
Symptoms usually occur about 2 to 10 days after coming in contact
with the virus. In some cases, SARS started sooner or later after first
contact. People with active symptoms of illness are contagious. But it
is not known for how long a person may be contagious before or after
symptoms appear.

TREATMENT :
1) Rp.: Sol. Natrii chloridi 0,9% - 100,0 ml
D.S. intravenously. 1 time a day
2) Rp.: Sol. Nospani 2% - 2 ml
D.t.d. 10 in ampull.
S. 0.5 2 (2 / ..)
3) Rp.: Sol. Acidi ascorbinici 5 % pro injectionibus 1 ml
D. t. d. N. 10 in ampull.
S. 1 2 5
.
4)Rp.: Sol. Suprastini 0.25 % 1 ml
D.t.d. N. 5 in ampull.
S. 0,5 2 6 .
5) Rp.: Sol. Analgini 50% 1,0
D. t. d. N. 6 in amp.
S. 1
6) Rp.: Sol. Euphillini 2% 1ml
D.t.d. N.10 in amp.
S. /.
7) Rp.: Sol. Natrii chloridi 0,9% - 150,0ml
Sol. Dexamethasoni 1mg
M.f.solutio.
D.S. . .
8)Rp.: Sol. Ringer-Locke pro injectionibus 100 ml
D. S. 10

( 6 )

PROGNOSIS :
The prognosis is good. There is no long term complication. And the
patient is completely cured so the prognosis is favorable.

EPICRISIS:
The patient's surname, name, patronymic, his age: ISHCHENKO
ZOKHORIYE , 11 MONTHS
Time and cause of hospitalization: 21-02-2016 ; HIGH TEMPERATURE,
CONJUNCTIVITIS & SORE THROAT
A diagnosis: SEVERE ACUTE RESPIRATORY SYNDROME
Data of the objective examination, which helped to make a diagnosis:
22-02-2016
The course of disease: 1 WEEK.
clinical diagnosis: SARS COMPLICATED WITH HYPERTHERMIA SYNDROME
WITH SYMPTOMS OF INTOXICATION
Treatment (conservative, operative): CONSERVATIVE
recommendation : the baby should be prevented from further any
kind of infection, proper care should be taken related to food, and
general hygiene. Also should be protected from extreme
temperatures.

USED LITERATURE :
Davidson book
www.google.com
www.wikipedia.com
lectures
notes
OP GHAI PEDIATRICS BOOK

KAPITAN