Beruflich Dokumente
Kultur Dokumente
GENERAL DATA
DV
Male
Roman Catholic
CP
3
weeks
PTC
2
weeks
PTC
1 week
PTC
CONSULT
PERSONAL HISTORY
1. Pregnancy Problems
2. Delivery
NUTRITION HISTORY
Feeding
A.
1.
GROWTH AND
DEVELOPMENT
Psycho-Motor/ Language:
Regard- unrecalled
Social mile- 2 months
Turned over- 5 months
Crept- 6 months
Sat aided- 7 months
Sat alone- 8 months
Walked independently- 12 months
1st words- 9 months
Put 3 words together- 1 year old
GROWTH AND
DEVELOPMENT
Developmental Level
a. General behavior- playful, active
b. Habits- no thumbsucking, no nail biting
c. Sleep pattern- sleeps around 9 PM and
wakes up around 6 AM
IMMUNIZATION HISTORY
C. Immunizations
BCG
at birth
Hepatitis B
1 dose
Hib
3 doses
OPV
3 doses
DTP
3 doses
Measles
1 dose
MMR
1 dose
Rotavirus
NONE
Hepatitis A
NONE
PCV
NONE
Varicella
NONE
Influenza
NONE
No Allergies
No previous hospitalizations
No Accidents/Injuries
No previous surgeries
FAMILY HISTORY
(+) hypertension - maternal grandmother
(+) Diabetes - maternal grandmother
(-) Bronchial asthma
(-) Allergy
(-) PTB
SOCIAL AND
ENVIRONMENTAL HISTORY
REVIEW OF SYSTEMS
HEENT- no eye/nose/ear discharge
Cardiovascular- no fainting spells
Respiratory- no cough, no colds
Gastrointestinal: no abdominal pain, no vomiting, no
diarrhoea
Genitourinary- no hematuria, no pyuria
Metabolic- no heat/cold intolerance
Musculoskeletal- no swelling, no limited motion of extremities
Nervous System- no convulsions
PHYSICAL EXAMINATION
Temperature: 36.5 C
Heart rate: 117 bpm
Respiratory rate: 22 cpm
Weight: 14.1 kg (z > 0)
Length: 91 cm (z < 0)
Head circumference: 49 cm (z > 0)
Chest circumference: 52 cm
Abdominal circumference: 50 cm
PHYSICAL EXAMINATION
General Appearance: awake, alert, oriented, unkempt,
not in cardio-respiratory distress
Skin- warm, moist skin, good skin turgor, (+) multiple
erythematous papule with crusting and excoriations over
both hands, feet, and anterior legs
Lymph nodes- no cervico-lymphadenopathy
Head- normocephalic, no head lesions
Eyes- no lid lesion, anicteric sclera, pink palpebral
conjunctiva, pupils 2-3mm, equally reactive to light and
accommodation
PHYSICAL EXAMINATION
Ears - normal set ears, no aural discharge, no tragal tenderness,
nonhyperemic ear canal, intact tympanic membrane
Nose - nasal septum midline, pink nasal mucosa, no congestion
of turbinates, no discharge
Oral Cavity- moist lips, pink moist buccal mucosa, no oral ulcers,
tonsils not enlarged, non-hyperemic posterior pharyngeal wall
Chest examination- symmetric chest expansion, no visible
retractions, normal breath sounds
Heart and Vascular- adynamic precordium, normal rate, regular
rhythm, no audible murmur
PHYSICAL EXAMINATION
Abdomen- flat abdomen, normoactive bowel
sounds, soft, nontender, no palpable mass
Genitals- SMR 1, no gross lesions
Extremities- warm; full and equal pulses; CRT
<2 seconds
PHYSICAL EXAMINATION
Neurological (General)
Sensory- no sensory deficit
Motor- can move all extremities
Reflexes- ++ (all extremities)
Cranial Nerves- intact
Gait- can walk independently
SALIENT FEATURES
nocturnal pruritus
unkempt
no fever
IMPRESSION
SCABIES
APPROACH TO
DIAGNOSIS
DIFFERENTIAL
DIAGNOSIS
Insect Bites
atopic dermatitis
Scabies
Bites
Inflammatory reaction at
the site of the punctured
skin, to the insects
venom
or
saliva
containing
histamine,
enzymes,
agglutinins,
serotonin, formic acid, or
kinins. Accompanied by
pruritic local erythema &
edema
pruritic
red
papules
typically
with
a
surrounding swelling & a
central punctum
Insect Bites
INSECT BITES
pruritic
red papules
surrounding swelling
central punctum
PATIENT
with pruritic
erythematous
and papules with excoriations
no central punctum
house has no
water reservoir
nearby
Atopic Dermatitis
Atopic Dermatitis
ATOPIC DERMATITIS
pruritic
papules
often
PATIENT
pruritic erythematous
papules with excoriations
lichenified, indurated
plaques whch are intermingled
with isolated, excoriated
site: hands, feet, anterior
papules
legs
site
of predeliction: antecubital
no family history of atopy
and popliteal fossae, flexor
wrists, eyelids,face, and around
the neck
no chronically relapsing
family
history of atopy
chronically
relapsing dermatitis
dermatitis
SCABIES
Infestation
scabiei
Generalized
intractable pruritus
Pruritic
papular lesions,
excoriations and burrows
Finger
Transmission:
contact
Skin to skin
SCABIES
SCABIES
PATIENT
pruritic erythematous
papules with excoriations
nocturnal pruritus
pruritus widespread
concentrated on hands,
feet, and body folds
SCABIES
CLINICAL DIAGNOSIS
SCABIES
bristles
body
legs
ETIOLOGY
RISK FACTORS
TRANSMISSION
SKIN-TO-SKIN
CONTACT
PATHOGENESIS
CLINICAL MANIFESTATIONS
Intense and generalized pruritic rash that is
CLINICAL MANIFESTATIONS
Burrows are most commonly found on the
CIRCLE OF
HEBRA
DIAGNOSIS
POSITIVE DIAGNOSIS IS MADE ONLY
BY THE DEMONSTRATION OF THE
MITE UNDER THE MICROSCOPE
MANAGEMENT
Permethrin 5% cream
applied to the entire body from the neck down, with particular
attention to intensely involved areas
MANAGEMENT
COMPLICATIONS
Eczematous dermatitis
Impetigo
Ecthyma
Folliculitis
Furunculosis,
Cellulitis
PREVENTION
PLAN
A: Scabies, resolving