Kharkov National Medical University

Department of Propedeutics pediatrics

The head of the department:

professor T. Frolova

Case history

The patient’s _______________________________

name, surname, age
Diagnosis
_________________________________________________________________________
______________________________________________________________________

Student__________________
Group___________________
Faculty__________________
Year____________________

Date of giving the history for checking up___________

Mark _______________________________________
Teacher’s signature___________________________
Date “___” _______2015 yr
 I. Demographic data
1. Patient’s surname, first and second name.
2. Age, date of birth. Age in months and days (for infants).
3. Sex (male, female).
4. Information about the parents: surname patronymics,
first and second name, occupation, place of employment.
5. Patient’s address: region, district, town, village, and
street, house, flat number, phone number.
6. Information about the child’s education: does the child live
in the family or in the children establishment.
Does the child attend: kinder-garden or school (address,
telephone number of this organization.
7. Date of the admission to the hospital.
8. Information about the organization, which referred the patient to the hospital.
9. The diagnosis of the doctor who referred the patient to the hospital
10. Date of discharging from the hospital.
II. Patient’s complaints
Ask the parents or the child about the causes of his (her) visit. First, enumerate
complaints, second – ask about the details of the complaints. Be as specific as possible and try
to record what the patient or his parents say accurately, without interpretation.
Doctor writes all complaints and determines chief and additional ones. Then doctor
makes detailed description of every complaint.
1. General symptoms of disease (temperature, chill, appetite, thirst, flabbiness,
restlessness, mood
2. Symptoms of disease in other systems and organs:
a) muscle-bone system: pain in the muscles, muscular spasms, muscular weakness,
hypotonia or hypertonia of muscles, pain in the extremities (character, location, connection with
weather changing), pain and constrained in the joints, movements of the joints limited,
deformation of vertebrae, extremities, joints; reddening of the skin in the region of joints.
b) respiratory system: sneeze, changing of voice, pain in the chest, cough (kind of cough,
wet, dry, time), sputum (quantity, character and colour, connection with breath and cough),
dyspnea (short breath): inspiratory, expiratory, mixed;
c) cardiovascular system: dyspnea, pain in the heart (character, location, radiate to back,
the shoul-derblade, the arm, the neck), palpitation (suddenly, gradually), edema (localization,
time);
d) digestive system: appetite, thirst, dysphagia (solid or fluid food only, suddenly or
gradually), regurgitation (belch), nausea (sick), vomiting, eruction, pain in the abdomen
(character, location, radiate, time, connection with eating, permanent or periodic). Stools (rate,
character, colour, smell, pathological admixture in faeces, without admixtures;
e) urorenal system: pain in the lumbar region (characteristic, radiate, time), pain during
urination, color of urin (dark, bright, yellow), passing urine rate, enures. pain in the lower
abdomen, bladder pain, renal colic, urination rate, painful difficult urination, involuntary urination,
correlation of day time and nocturnal urination.
f) endocrine system: - changing of voice,

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 - disturbance of the hair growth (alopecia, hypertrichosis),
- changes of skin (excessive sweating, dryness;
- disorders of growth (gigantism, nanism) and body mass (malnutrition, obesity)
g) nervous system: ability to work, mood, memory, attention, sleep,
- headache: location, character, intensity, permanent, periodic, duration, cause; accompanying
symptoms: pulsation, burning, pressing,
- giddiness (dizziness),
- tics (indicate the location),
-convulsions (cramps),
- hypo-, hyperestesia,
- disorders of feeling, and speech organs.

III. History of the disease (Anamnesis morbi)

(according parent's or child's information)
1. Development of the disease is described in chronological order since the moment of it’s
onset to the moment of examination. The cause of the disease. Development of symptoms: the
date of the disease onset (acute or indefinite); the first symptoms and signs of the disease;
describe duration of remission and the patient’s state in this period;
2. Preliminary examination and diagnosis, results of paraclinical investigation;
3. Information about medical treatment: its effectiveness.
4. Aim of the patient’s hospitalization and its way (planned or urgent admission).

IV. Life history

(child from the moment of birth - 3 yrs old)
1. The child was born from I, II,… pregnancy.
2. Obstetric history: mother’s health during pregnancy; life, job, nutrition condition during
pregnancy. Peculiarity of pregnancy, gestosis, delivery.
3. Information about previous pregnancies: abortions, their causes, and term of pregnancy
when abortion happened. Information about stillborn, child death in the family causes of child
death.
4. Peculiarity of the delivery, complications, medical assists.
5. Newborn condition: physical development (weight, length, head and thorax
circumferences at birth), information about conclusion by Apgar scale (if mother knows).
6. Newborn period: physiological loose of weight, the term of the separation of the umbilical
cord and healing of the umbilical wound, diseases of newborn. The term of newborn discharging
from maternity house. Home-nursing.
7. Feeding of the newborn. When did the newborn have the first breast-feeding, did the
newborn have any difficulties during the first breast-feeding? Feeding of the infant at first year of
life (breast feeding, bottle-feeding or mixed feeding). Type of feeding formula used. The term of
introduction of solid food, ceasing of breast-feeding. Feeding of the child at the moment of
admission to the hospital.
8. Characteristic of physical development of the child: weight, height, head, thorax
circumference development (data on admission). Mark the time when the child started to keep

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the head up, to sit, to stand, to walk, the time of the first teeth eruption, teeth formula on
admission.
9. Psychological development: mark when the child started to fix the subjects by eyes, to
smile, to pronounce the first words, to speak. Child's behavior in the family, in children’s
collective, at school, progress at school. The beginning of teething.
10. Somatic diseases (in chronological order). Mark the character of the disease, peculiarity
of the clinical characteristic, pay attention to allergic diseases, to the food and drug intolerance.
Information about surgical operations, traumas and etc.
11. Information about tuberculin sensitivity, Mantoux test result, date of testing.
12. Information about prophylactic vaccinations, reactions to vaccination.
13. The child's hygienic regime: the term of being out-of-doors, sleep condition, bathing.
14. Index of infections disease

V. Life history (children 3 – 18 yrs old)

1. The child is first, second, third and so on in the family.
2. Describe the patient’s education: when he (she) went to kinder-garden (school), school
success, hobbies, free time activities and etc.
3. Previous infection and somatic diseases (in chronological order). Mark the character of
the disease, peculiarity of the clinical characteristic.
4. Information about surgical operations, traumas and etc.
5. Allergic history: ask about food and drugs allergic reaction.
6. Information about tuberculin sensitivity, Mantoux test result, date of testing.
7. Information about prophylactic vaccination, reactions to vaccination.
8. Index of infections disease

VI. Family history

1. Parents’ age, health condition of other members of the family, including brothers and
sisters age, health condition. Are there in the family: venereal diseases (syphilis, gonorrhea,
AIDS, and etc.) alcoholism, psychiatric diseases, tuberculosis, endocrine, allergic diseases,
cancer, and hepatitis.
2. Family material status and living conditions.
3. Parents’ working conditions. Free time activities, dietary regimen, and etc.
4. Make genealogical tree.
Summary diagnostic conclusion according to the patient’s complains, anamnesis of
diseases and life history.

VII. Present state (on the date of examination)

1. General state of the patient is satisfactory, middle grave, grave and extremely grave.
Patient's position in a bed is active, active with restriction, passive, forced.
State of consciousness: clear, disorder (stupor, sopor, coma), excitement, delirium.
Estimate reaction to patients, physician, nature of the cry and facial expressions (calm,
excited, sad, lifeless, Hippocratic face, mask-like, etc.).

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2. Physical development and its assessment
Weight in kg, height in cm, circumference of the head and the thorax in cm.
The result of investigation must be compared with the age standards.
Assessment of physical development as average, state of the degree and character of
deviation from standard.

3. Nervous system:
- assess child development according to the age;
- assess the developmental reflexes in newborn – Moro’s reflex, tonic neck reflex,
stepping reflex, Babynsky’s reflex, planter reflex, palmar grasp, traction, response, root reflex,
sucking reflex, swallow and gag reflex (reflex is normal, decreased, absent);
- state of sense organs: vision, hearing, skin sensibility, olphactory, and taste
characteristic;
- state of the brain enervation, skin and deep tend on reflexes, vegetative innervation’s
according the result of dermographism investigation;
- abnormalities of gait, posture, coordination.

4. Skin
Inspection: -colour (light pink, flash-coloured, sunburn- coloured, pale, cyanotic,
hyperemic, icteric, dark, etc.),
-adnormal pigmentation (depigmentation, hypopig-mentation, hyperpigmentation,
albinism);
-rashes (size, colour, persistence, distribution, position); scars (site, size, shape, colour,
connection with underlying tissues, mobility, and etc.); striae; hemorrhagic manifestations;
hemangiomas, angiotelectasia; Mongolian blue spots, cafe-au-lait spots, vitiligo, etc.
- vascular (capillary) symptoms: symptom of the tourniquet, symptom of the hammer,
gavel, symptom of the pinch, nip and tweak.
- edemas are absent or present (to indicate location, symmetric).
- dermographism (red or white).
- the skin derivates: describe hair (colour, thickness, pathological changes, etc.) and nails
(form, colour, pathological changes).
Palpation: skin temperature, wetness of skin,
- corpulence, thickness of skin tuck,
- skin elasticity
Visible mucous membranes and conjunctivae: colour, clear or not, humidity.

5. Subcutaneous fat
Inspection: -its development (sufficiently (enough), is not enough (poor), excessively
developed, (obesity) and distribution (uniform, deposits),
- thickness of subcutaneous fat tuck ,
- turgor of tissue.

6. Lymph nodes

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 Inspection: - lymph nodes is visible or not, symmetry (symmetric, asymmetric),
- the change of skin over the lymph nodes.
Palpation of lymph nodes - their size in cm if enlarged, shape, their consistence, mobility,
density, surface, tenderness, connection with underlying tissues and skin.
- one should routinely attempt to palpate suboccipital, preauricular, anterior cervical,
posterior cervical, sub-maxillary, sub-linqual, axillary, epitrochlear, cubital and inguinal lymph
nodes.

7. Muscle system
Inspection: development degree of muscle system (average, well-muscled, poor) and
symmetry.
Palpation: muscle tone, muscle strength: sufficient, decreased (to indicate where).

8. Bone system
Inspection: - head (size, shape, symmetry), cephal-hematoma, bossae, craniotabes,
- fontanel (size, tension, closed abnormally late or early), suture, dilated scalp veins.
- teeth state: temporary or permanent teeth, teeth formula, caries presence; bite (right or
not);
- Chest: - shape (cylindrical, conical, pigeon breast, funnel shape, barrel (cask) shape) and
symmetry of the thorax, retraction, Harrison's groove, flaring of ribs.
- skeleton deformation: physiological deformation (kyphosis, lordosis), pathological
deformation: scoliosis, kypho scoliosis, lordosis (to indicate part and degree).
- extremities: “o-form”, “x-formed”, feet deformation, pathologic fracture (to indicate
location). Tenderness: painless (to indicate location).
- joints: their configuration, symmetry, skin over the joints.
Palpation: active (free, in complete volume or limited in mobility, sharp limited in mobility,
immovable - to indicate which) and passive movements of the joints (free, in complete volume,
limited in mobility, immovable - to indicate which).

9. Respiratory system
Inspection: -state of respiration type (thoracic, abdominal, mixed).
-assess respiration rhythm (rhythmic respiration, arrhythmic respiration, Cheyne-Stokes
respiration, Biots respiration, Grocco's respiration, Cussmaul respiration).
-assess the shape: cylindrical, conical, barrel (cask) shape; symmetry of the thorax during
the breath, retractions, flaring of ribs;
- respiratory rate.
- type of dyspnea (inspiratory, expiratory, mixed), participation of additional muscles in
breathing.
Palpation of the chest:
-pain in the chest wall (painless or painful, to indicate location);
-vocal fremitus (vocal fremitus of the middle strength, the same on the symmetrical parts,
vocal fremitus is decreased, increased on the one half of the chest, local changes of vocal
fremitus - decreased or increased - indicate location;
-symmetry of subcutaneous fat tuck ;

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 -elasticity and resistance of the chest (the chest is moderate elastic and moderate
resistance, elasticity of chest is decreased, the chest is rigid).
Percussion of lungs.
- comparative percussion of the lungs (clear pulmonary sound; dull pulmonary sound -
indicate location; tympanic sound - on all parts of the chest, on one part of it, local - to indicate
location; bandbox sound; cracked-pot sound - to indicate location; metallic sound - indicate
location; dull with tympanic tone - indicate location);
- topographic percussion: - assess the lower border of the lungs (the lower borders of the
lungs are displaced downward or upward on one or on the both sides, the lower border of the
lungs is in a form of Damuasou curve);
- respiratory mobility of pulmonary borders by midaxillary line (cm).
Auscultation of the lungs:
- main respiratory sounds (pueril, vesicular breathing, decreased vesicular breathing,
indicate location of weakening of vesicular breathing, increased vesicular breathing, harsh
breathing, vesicular breathing with longer expiration, bronchial breathing, amphoric respiration).
- adventitious respiration sounds: 1) dry rales, high, pitched, sibilant, low-pitched,
sonorous, 2) moist rales (fine bubbling, medium bubbling, coarse bubbling, consonating and non-
consonating, 3) crepitation - initial, resolve, pleural friction sound, to indicate location of
adventitious respiratory sounds.

10. Cardiovascular system

Inspection: - presence of the chest deformity in the heart region (the chest deformity is
absent, the chest deformity is present: "humpback" and etc.);
-presence of the apex beat (the apex heat is not determined, the apex beat is
determined: positive or negative);
- the cardiac beat (absent, present), presence of the pathological pulsation in the 3 rd _ 4th
interspaces to the left of the sternum, in the 2 rd interspaces to the left and to the right of the
sternum edge, presence of remote pathological pulsation, in the epigastric region, in the liver
region (absent, present).
Palpation: - the apex beat, location, the width, the height, the strength (middle strength,
strong, weak, like a dome;
- presence of the "cat's purr" sign (absent present, indicate location);
- palpation in the pulsating liver region (true liver pulsation, transmitted liver pulsation);
- examination of pulse in of temporal, carotids, subclavian, brachial, thorax, radial arteries
and etc., (see examination of vessels).
Percussion of the heart. The borders of relative cardiac dullness (right, upper, left).
Auscultation of the heart: - rhythm of the cardiac activity (regular, irregular determine the
type of rhythm disorder, extrasystole, fibrillation, etc);
- the number of beat sounds (two, three reduplication, splitting of the second sound over);
- the heart rate (HR) per minute. Assess HR according to the age norm, tachycardia, bradicardia;
- character of the heart sounds (the heart sounds intensity is sufficient, the heart sounds are dull,
the heart sounds are voiceless, the heart sounds are loud, the first heart sound at the apex is
increased, snapping or diminished, the 2nd sound over the aorta is increased or diminished, the

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2nd sound over the pulmonary artery is increased or diminished, the 2 nd sound over the pulmonary
artery is reduplicated (splitted);
- cardiac murmurs are not heard, are heard (indicate location and transmission, systolic, diastolic
murmur, at the heart apex, 2nd interspaces, over the aorta, over the pulmonary artery, in the 5 th
point).
Examination of the vessels:
- aortic pulsation (invisible, visible, indicate location);
- peripheral arteries (temporal, carotid, subclavicular, brachial, intercostal, invisible,
visible).
- subcutaneous veins (jugular, veins of the upper and lower extremities, veins on the front
surface of the chest and abdomen are invisible, visible (describe), general swelling of the veins,
local swelling of the veins (present, absent).
Palpation. Examination of pulse on the radial artery:
-comparison of the pulse on both rate hands (pulse is same on the both hands, is different on
different hands),
- rhythm of the pulse waves (the rhythm is rhythmic, arrhythmic),
- pulse rate per minute, pulse deficit, pulse pressure (satisfactory tension, the pulse is hard, soft),
- volume of pulse (of satisfactory volume, the pulse is full, the pulse is empty,
- pulse character (of middle size, the pulse is large, the pulse is small, the pulse is threadlike),
- pulse rate (the pulse of middle rate, the pulse is quick, the pulse is slow),
- pulse character (quick, and high, slow and small).
Examination of the arterial pressure (AP):
1. Systolic (SAP);
2. Diastolic (DAP);
3. Pulse pressure (PP).
Assessment of AP: normal, pathological.

11. Digestive system

Inspection - condition of the oral mucous, throat, tonsils (colour - pink, hyperemia, dry or
moist, coated tongue follicles, fissures, geographical tongue).
NB! Inspection of the oral cavity is conducted in the end of the examination.
- shape and size of the abdomen (distended abdomen, symmetric, hollow, board-like abdomen,
swelly abdomen, frog abdomen), condition of the umbilicus, visible peristaltic, respiratory
movements, umbilical veins, hernia.
- examination of the perianal area (gaping anus, mucosal prolapse of the rectum, fissures of the
anus).
Palpation:
- superficial palpation: muscular tenderness and rigidity, painful points, local infiltration (soft
abdomen, abdominal distension, tympany, meteorism, tense abdomen, surgical ("acute”)
abdomen, location of painful points).
Deep palpation of the intestine: its length and diameter in cm, shape (cylindrical),
consistence (tenderness or thick, mobility, sickliness (morbidity, painfulness), rumbling,
- Liver palpation (liver is not palpated, palpated for 1.5-2.0 cm or more below the rib arches, its
consistency - soft, firm, shape, type of margin - rounded, sharp, tenderness.

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 Percussion of the abdomen, detect ascites (fluid wave, fluctuation). Percussion of the
liver (the upper margin of liver is defined, along the mammillary line in the fifth intercostals
space).
Auscultation of the abdomen (intestinal peristalsis, intestinal tones - marked, not marked).
Stool, its character, colour, consistence, pathological admixture, frequency of stool
(orange-yellow, homogenous, sourish stool, shaped, pale grey, pale yellow, dryish, foul,
starvation stool, dyspeptic stool - loose, watery, green, in form of discrete flakes, admixture of
mucus and blood, bulky, greyish, dark-brown stool).

12. Urorenal system

Inspection of lumbal region.
Palpation: bimanual palpation of kidneys (kidneys are palpated, are not palpated). Painful
points (pain in the lower abdomen, low back pain, bladder pain), pain in the urethra.
Percussion of the urinary bladder (a smooth, elongated fluctuating tumescence is
palpated above the symphysis pubis, percussion produces a flat sound above it).
- Pasternacky's sign (negative or positive).
- Urination rate.
- Painful difficult urination. Involuntary urination. Correlation of day time and nocturnal
(night time) urination (diuresis).

13. Endocrine system

Disorders of growth (gigantism, nanism), and body mass (malnutrition, obesity);
- allocation of subcutaneous adipose tissue;
- condition of thyroid gland (lobe and isthmus size).
- observation of genitals (development of genitals correlate with the age, degree of
development of secondary sexual characteristic).

14. Results of paraclinical methods of investigation (general blood analysis, urinalysis,

coprogram, bacteriologic tests, biochemical examination, X-ray examination). Assessment of the
laboratory findings and instrumental investigation, correlation with age standards. Conclusion,
assessment of pathological deviation.

Summary diagnostic conclusion according to the patient’s complains, anamnesis morbi

and vitae, main pathological symptoms and syndroms which were found and results of
paraclinical investigation.