We are beginning course of practical Pediatrics.

At IV course we studied theoretical course of pediatrics

and now Ill try to teach how to use knowledge, obtained at IV course in practical life

First of all about documentation

Number 1 document for physician and patient is History of disease.
History of disease is the same for all countries and the same from the time of Hippocrates.
Besides, the History is the legal document and if you have some problems, the history is the best
defender

History composed by several parts

1. Passport data
2. History of current illness- Anamnesis Morbi
3. Past medical History , which may be Anamnesis Aegroty for children under 3 years and
Anamnesis Vitae for the elder children
4. Physical examinations - Status presence
5. Preliminary clinical diagnose
6. Needed laboratory and imagine tests
7. Clinical diagnose
8. Treatment

Information from the first three points is obtained from patient parent, the rest - physicians
considerations

1. Passport data

Ali, Valievi, 16y. , male, date of admission: 17.10.2017 20:09, chief complaint: Acute respiratory
insufficiency

2. History of current illness- Anamnesis Morbi

The Child is ill from 14.102017. The patient with progressive muscle dystrophy had contact with acute
respiratory infection bearing brother, after which respiratory complaints supervened. The patient
started experiencing noisy respirations, nasal discharge and poor cough reflex without ability to extract
sputum. The patient received treatment at home with ceftriaxone, lazolvan and berodual inhalation. In
spite of conducting therapy the patient's condition didnt improve, he developed perioral cyanosis and
subsequently was admitted to hospital.

4. Anamnesis Vitae after 3 year

Social-economic status is unknown. Mother 36y. Healthy. Father 41y. Healthy. 2 siblings - healthy
Immunization schedule
Diseases in past

5. Status presence - Physical examination

1. General condition Severe but stable. Body temperature is in normal ranges. Patient is on
mechanical ventilation with Synchronized Intermittent Mandatory Ventilation (Simv). The
 patient periodically receives ? Food intake through
nasogastric tube.
2. Posture involuntary
3. State of consciousness - alert
4. Skin pale, slightly decreased turgor, decreased subcutaneous fatty tissue
5. Respiratory system on mechanical ventilation (pre-simv), asthenic thoracic shape. Equal
pneumatization in left lung on x-ray. Right lung could not be evaluated due to scoliosis. Normal
positions of diaphragm. Normal mediastinal contours. Crackles on auscultation. Equal
pneumatization of both lungs and no infiltrations on CT.
6. Cardiovascular system - peripheral pulse rate 60 rhythmic and weak (117, increased force?)
synchronic. Heart tones- clear, no murmurs. Normal heart borders. Normal capillary refill.
7. Gastrointestinal system tongue without coating, clear oral cavity. Food intake through
nasogastric tube. Nausea linked to food intake. Abdomen- soft on superficial and deep
palpation. Liver and spleen borders under normal limits, defecation once daily, stool
consistency normal, without blood, fluid or mucus. High ALT & AST
8. Genito-Urinary tract Normal sexual signs. Frequency of urination 3 times, free. Urine
cloudy, yellow, normal specific gravity
9. Bone and Joints Thoracic and vertebral deformations. Thoraco-lumbar Scoliosis. Movements
limited.
10. Neurological examination Restless sleep, no pathologic reflexes, no tonic-clonic seizures,
fully alert.

5.Preliminary clinical diagnose

On the base of anamnestic and clinical signs, preliminary clinical diagnosis is pneumonia.

6 Needed laboratory and imagine tests

Chest CT
Bacterial Sputum Culture
Muscle biopsy for progressive muscle dystrophy
VBG
Liver and kidney blood analysis
Urinalysis

7. establish Clinical Diagnose

Pneumonia
Progressive muscle dystrophy

8.Treatment

Ceftriaxone 1g 2x, Azithromycin 250mg po 1x, prednizolon, asparkami 1 tab, NaCl inhalation,
Zantaci 25mg