V.N.KARAZIN KHARKIV NATIOONAL UNIVERSITY
MEDICAL FACULTY
DEPARTMENT OF PEDIATRICS
CASE HYSTORY
The patient’s_ Sophia ,10 years old ___________
Name, surname, age
Diagnosis
_______acute_bronchitis________
Student of 5th course
_Sahil ___
Group____528__
Date of giving the history for checking up_3/04/2022________________
Teacher’s signature_____ natalia rybak
I. PASPORT PART
1. Patient’s surname, first name, second name Sophia
2. Age, date of the birth_10 years old ,16/04/2010
3. Sex (male, female)
4.
Date of admission__2/03/2022_
II. PATIEN’S COMPLAINS
Ask the patient about the causes of his (her) visit.
1
General complains (temperature, chill, appetite, thirst, weakness, mood)_ _she
complains of cough ,fever ,difficulty in breathing , weakness, chills ,pain in muscles
and lungs.
Complains of diseases in other systems and organs:
NERVOUS SYSTEM: ability to work ________yes____, mood_ yes__________,
memory_yes___________,
attention__good___________,
sleep____sleep_apnea_________________
headache: location__in frontal part of head _, character cough headace
intensity___mild _, permanent or periodic; accompanying symptoms: pulsation,
burning, pressing;
dizziness___yes___ tics _vocal tics _convulsion____yes________
hypo -, hyperstesia_____no__
disorders of feeling and speech organs____no__
MUSCULAR-BONE SYSTEM: pain in the muscles__sever pain
muscular spasms_____yes______________muscular
weakness__yes_____________ pain in the joints
(SLIDA)_____mild_stiffness______________________________________
movements of the joints limited ____no___________, redness and swelling of the
skin above joints______no__
pain in vertebral column____yes_
RESPIRATORY SYSTEM:
sneeze___yes___________, congestion ___yes__________ changing of
voice_yes________ cough (dry or moist, deep or superficial, time of
appearance_moist,superficial,morning or at night mainly, duration, specific
sings)__3 to 10 days with mucus ,pain during cough . _
sputum (
amount_____small_______,character_purulent_mucous,odorless______________
________________, color____yellow-grey______________,
impurity)____yes_______________________________
pain in the chest____yes____, dyspnea (inspiratory, expiratory,
mixed)_____mixed_______
CARDIOVASCULAR SYSTEM
heart pain (character___yes___________
location__left_midclavicular_region___________, irradiation to the left arm, neck,
back)______yes____dyspnea__yes__palpitation__tactile_fermitus_normal______
edema localization _peripheral_____________time of appearance__while
coughing _________________
2
DIGESTIVE SYSTEM
abdominal
pain
(localization____yes______________
intensity_normal__________,
irradiation_______no________
time
of
appearance__while breathing _, connection with eating____pain while swolling _,
connection of pain with the act defecation___yes____
dyspeptic disorders: the thirst, difficulty swelling, regurgitation, heartburn,
eructation, nausea, vomiting;
disorders of defecations: diarrhea(rate, consistence of feces, color, smell, impurity)
_________no______, constipation (rate, consistence of feces)_________no_____,
disorders of appetite_____no_
URORENAL SYSTEM:
pain in the lumbar region: (characteristic, radiate, time ) _mild pain ,during
coughing and breathing _, pain in the lower part of abdomen_____yes__, changes
of urination (painfulness, rate )__no___, ratio of day time and nocturnal
urination)______no__
color of urine______normal
ENDOCRINE SYSTEM:
Changes of voice yes_
disturbance of the hair growth___no_ (alopecia, hypertrichosis).
changes of skin (excessive sweating, dryness)___no_______________________,
disorders of growth ______no__ body mass (malnutrition, obesity)__obesity
disorders of mensis_____no_
III. HYSTORY DISEASES
Development of diseases is described in chronological order. The probably causes
of the diseases. Development of symptoms. Previous investigations. Information
about treatment, its effectiveness.
__ firstly she complains about pain in chest ,coughing for long days and mild fever
,so after diagnosis she had acute bronchitis .hes_sputum cough leading to pneumonia
which further lead to acute bronchitis. On examination ,lung auscultation has
wheezing sound .
IV. PAST HYSTORY
Physical and psychomotor development in early childhood. When he go to the
kinder-garden or school, school success. _his physical development is normal ,well
good during school
3
Previous infection and somatic diseases._______he living in a polluted place due
to poor family history so he had asthma __
Information about surgical operations___no_____
Information about tuberculin sensitivity (Manty tests
result)____no_____________
Information about prophylactic vaccination _____________negative___________
reactions on vaccination__no____
The child’s hygienic regime___living in polluted area
Family history: presence in family heredity diseases, alcoholism, psychiatric
diseases, cancer.
Family material status and living conditions.
_____________he have 3 sister ,only one person who earn money ,so his family
condition is not good
Lives in polluted area .
Allergic history: presence of allergic diseases in child, his parents; presence of
unusual reactions on the food, plants, smells, insects, animals and so on.
__________allergy to pollen
Epidemiological anamnesis: presence of contact with the infectious patients for the
last 3 weeks, epidemiological surroundings in child's establishment which is visited
by a child. Contact in the family with venereal diseases (syphilis, gonorrhea, AIDS)
tuberculosis
_____________no such history _
V. OBJECTIVE EXAMINATION
General condition of the child: satisfactory, moderate, severe, very severe (choose).
Patient’s feeling satisfactory, no satisfactory reaction to others: adequate, negative
(choose).
Position
on
the
bed:
active,
passive,
compelled
__________________________________________________________________.
Consciousness: clear, stupor, sopor, coma, excitement (choose).
PHYSICAL DEVELOPMENT OF CHILD
Estimations of all parameters are provided with percentile tables: average, above
the average, less than average, excessive, low, extremely excessive and extremely
low.
Weight)___12___(kg)___________height___1.35_____(cm),_________________
____
BMI_____10.3kg/m2_________________________________________________
________
head circumference___55___ (cm), chest circumference _57______(cm).
CONCLUSION: physical development satisfactory, delay, biology acceleration
4
Average but accelerating
__________________________________________________________________
________________________________________________________________
NERVOUS SYSTEM
Psychomotor development speech__no___________, sensory: vision__no__
hearing__yes________ skin sensibility__________ (parastesia, hyperstesia,
anesthesia),
olphactory
function
normal____________
taste
function___normal_____________
,
intellect
activity__normal_____________,
motor
activity____abnormal__________________,
(Corresponds or not to age)
Stigmatic of embriogenesis (micrognatia, macrognathia, low or asymmetrical
located ears, deformation of earlobes, low growth of the hair on the forehead, falling
or sinking down of the eyelid, torticollis, a significant amount creases on the neck,
protrusions umbilicus, polydactyly, brachidactyly, arachnodactyly, syndactyly,
overlapping, camptodactyly) _______no________________________
vegetative innervation’s according the result of demographic investigation ( white
or red)
Abnormalities of gait___________no____________________________________
Coordination (is checked with Romberg’s position (posture is stable or
not)_________________________no____________________________________
__________________________________________________________________
__
finger–nose
test
(presence
or
absence
of
distaxia)_____no______________________
heel-knee
test________________no________________________________________
Presence of pathological symptom or not: Kernig’s, Brudsinsky’s upper,
Brudzinsky’s lower, rigidity of occipital muscles_______yes___________
SKIN, SUBCUTANEUS TISSUE
Color of skin: usually color, pink, pale-pink, pale, yellow, gray, cyanotic
(acrocyanosis, perioral cyanosis, periorbital cyanosis, cyanosis of the nasolabial
triangle)(choose).
Rash on the skin: primary lesions: macula, patch, papule, plaque, nodule, tumor,
vesicle, bulla, pustule (choose); secondary: pigmentation, crust, fissure, erosion,
ulcer, scar, lichenification, hemorrhagic rash (choose); localization: quantity: excess
itching: No
Temperature of skin: moderate warm, cold, hot,
Dryness or moistness: moderate moist, moist (indicate
location)__moist_in_chest__________
__________________________________________________________________
dry (indicate
location)___dryness_in_chest__________________________________________
Elasticity: normal, decreased, increased.
5
The thickness of subcutaneous tissue on lateral surface of abdomen on the umbilical
level ____cm, on subscapular place ___ cm, internal surface of thigh ___cm, on the
middle of third of foream ___ cm. Development of subcutaneus fat is: sufficiently,
poor, excessively developed
Distribution of subcutaneous fat: uniform, deposits
__________________________________________________________________
Tissue turgor: satisfactory, decreased, increased (choose).
Edema: present or not,
location___peripheral_____________________________________________
Lymphatic nodes
Groups: occipital anterior posterior cervical submandibular: supraclavicular_
undercavicular axillary, cubital, inguinal (describe their localization, quantity, size,
shape, , adhesion of nodes between themselves, elastic or dense, painfulness, skin
temperature above nodes)
MUSCULAR SYSTEM
Degree of development of muscle mass: low, middle, good; symmetrical or
asymmetrical (choose).
Palpation of muscles: painless, painfulness; consistent (density, moderate density,
soft)
Muscular strength: muscular strength of fingers of hand_weak____________,
__________hands,
____weak________forearms,___weak_______
arm,
________upper shoulders (sufficient, reduced, presence weakness of muscles;
symmetrical or not) Muscular tone: is sufficient or presence of atonia, hypotonia,
hypertonia (indicate location)___hypotonia____
________
SCELETAL SYSTEM
Inspection of head: size:55 cms circumference shape: Normal symmetry: Normal,
presence craniotabes or not.
Teeth state: caries presence or not
Posture state: normal, lordosis, kyphosis, scoliosis, kyphoscoliosis (choose).
Estimation of chest: shape (norm, deformation) enlarged
Extremities: O-form, X-formed, feet deformation, flat foot, norm foot
Estimation of joints: check all group of
joints___normal___________________________
Pathological changes :
location___________deformation_______yes_____________, size_____changes
_____________, edema____no_______________, redness__no__________, hot
skin_____yes_________, painfulness during palpation__yes_________, during
active movement limited in mobility______yes________, during passive
movements limited in mobility __________yes__________________
RESPIRATORY SYSTEM
Nasal breathing: free, congestion.
6
Nasal secret: character (aqueous, mucous, mucous-purulent, purulent); quantity
(insignificant, moderate, significant), impurity (absent or blood impurity); smell
(absent, rotten)_
Voice: normal, hoarse, snuffing, aphonic.
Cough during examination: dry, productive, less productive; superefficient or deep;
short – or long- termed; accompanied with vomiting or not; specific cough
(whooping, barking, brassy)
Sputum during examination: absent, quantity (significant, insignificant);
consistency (watery, viscous); character (mucous, mucous-purulent, purulent,
bloody); smell (absent, stinking); presence of blood (the excretion which looks like
pink foam, red color, like compact clots, dark red ).
Type of breathing (thoracic, abdominal, mixed; corresponds to age or not)
Assess respiration rhythm: rhythmic, arrhythmic, Cheyne – Stoke’s, Biot’s,
Cussmaul’s respiration.
Respiratory rate: normal, tachypnea, bradypnea.
The breathing rate in children
Age
Norm
3-4 years
30-35
5-10 years
20-25
Over 12 years
16-20
Patient’s breathing rate
Character of dyspnea: absent, inspiratory, expiratory, mixed;
participation of additional muscles in respiration (are present or not) suprasternal
fosse__no________nasal flaring___yes___________ retraction of intercostals
space______________________no______________________________________
PALPATION OF CHEST
Superefficient palpation of chest: painless, painfulness during superefficient
palpation
(indicate
location)_left_ventricular_region________________________________________
_
Assess of vocal fremitus: in norm – middle strength, the same on the symmetrical
parts; decreased or increased (indicate
location)_left_midclavicular_region________________________
__________________________________________________________________
Deep palpation of chest: painless, painfulness during deep palpation (indicate
location____________painful during deep palpation,
Resistance of chest: satisfactory, decreased, increased.
PERCUSSION OF LUNG
Comparative percussion: vesicular resonance over both side of lung; decreased of
resonance; dull sound, tympanic (indicate location) _subclavicular_region,_vocal
fermittus_____________________
7
Topographical percussion:
upper borders of lung on anterior side (in norm over 10 yr.o. 2-4 cm above
clavicle): 5cms above clavicle
upper borders of lung on posterior side (in norm on level of spinal process of VII
cervical vertebrae): on level of spinal process of Vlll cervical vertebrae width of
Kroning’s area (in norm over 10 yr.o. 3-5 cm) ___6 cm__________________;
inferior borders of lung on mediaclavicular, medioaxillaris, scapular lines
(complete
tab.1);
excursion
of
lung
(in
norm
2-4
cm)_____normal___________________
Table 1
The inferior borders of lung in children
Line
The side
Midclavi сular
Middle axillary
Right
Left
Right
Scapular
Left
Right
Left
Age of the child
Till 10 years
More than 10 years
VI rib
VI rib
VII – VIII rib
VIII rib
IX rib
IX – X rib
X rib
patient
VIII rib
X rib
X rib
AUSCULTATION OF LUNG
Characteristic of breath sound
over trachea (in norm bronchial breath
sound)_abnormal____________________________
over I-II intercostals space and over interscuapular area (in norm broncho-vesicular
breath
sound)_____abnormal________________________________________________
__ over lung (in norm vesicular breath sound)
___________________abnormal____________
diminished breath sound) (indicate location)
Near the right midclavicular absence of breath sound: No amphoric breath sound (
indicate location): Left scapular region.
adventitious respiratory sounds: coarse crackles, fine crackles, low pitch wheezes,
high pitch wheezes crepitation, plural rub (indicate location, quantity, phase of
respiration( during inhalation or exhalation), disappearance after cough up or not
Plural rub near middle axillary during exhalation
__________________________________________________________________
Bronchophony: not changed, increased –on one side or both side
CARDIOVASCULAR SYSTEM
Inspection a heart area:
Cardiact hump (in norm absent); Precardiac activity (presence or not)
carotid pulsation (present or not); neck vein enlargement
pulsation in epigastric area (present or not).
Palpation
8
Assess of pulse on radial artery: rate (normal, tachycardia, bradycardia) ( tab.2);
rhythm (regular-regula, regula –iregula, iregula-iregula); size (normal high, low,
weak, alternating pulse); tension (pulse normal pressure, hard, soft); filling
(satisfactory, full, less filling).
Table 2
Pulse rate in children
Age
Pulse rate
3 years
105-100
4
100-105
5
98-100
6
90-95
7
85 - 90
8-9
80-85
10-11
78-84
12
75-82
13-14
72-80
patient
Palpation of apex beat: location (tab.3), extension (in norm area of apex beat is not
more than 1x1 cm, in older children – 2x2 cm)__left medioclavicular line
________________, force (moderate, increased, decreased)____increased
Table 3
Location of apex beat in children
Border
Till 2 years
2-7 years
7-12 years
Above 12 years Patient
Right
IV –V intercostal 1 cm lateral to
space 1-2 cm left
lateral to the left medioclavicular
medioclavicular line
line
7-12 years – on 0,5 cm to the
left
middle from the
medioclavicular left
line
medioclavicular
line
Percussion of heart: determination of relative and absolute dullness of heart (tab.4,
tab.5)
Table 4
Borders of relative heart dullness and transversal heart distance
Age
Right
Till 2 years
2-7 years
7-12 years
Above
12
years
The
right Inwards from In the middleLines, closer to
parasternal line the right side between
thethe latter, after
parasternal line right
some yearsparasternal andright
9
right
line
Upper
II rib
sternalparasternal
line
II
intercostal III rib
space
III rib or III
intercostal
space
Left
2 cm outwards 1 cm outwards 0,5 cm outwardOn the left
from
left from left
from
mediaclavicle
mediaclavicule mediaclavicule mediaclavicle line or 0,5 cm
line
line
line
inwards
Transversal 6-9 cm
8-12 cm
9-14
9-14
heart
distance
Table 5
Borders of absolute heart dullness and transversal heart distance
Age
Till 2 years
2-7 years
7-12 years
Right
Left sternal line Left sternal line Left
line
Above
years
sternalLeft sternal
line
12
Patient
Upper
II
intercostal III rib
III intercostalIV rib
space
space
Left
Closer to the
On the left Closer to theLeft
left
medioclavicular left
parasternal
medioclavicular line
parasternalline line
(outside)
(outside)
Transversal 2-3 cm
4 cm
5-5,5 cm
5-5,5 cm
heart
distance
Auscultation of heart
Characteristic of the heart sound in all point of auscultation ( loudness, rhythm,
clearness ), abnormal sound: split S1, split S2 paradoxical, widened, fixed, aortic
ejection click, pulmonary ejection click, opening snap; murmurs (intensity, time of
appearance (early systolic, later systolic, diastolic early, diastolic later, mid diastolic,
continuous), duration (long, short), configuration (crescendo, decrescendo,
crescendo - decrescendo), quality (harsh, rumbling, scratchy, grunting, blowing,
squeaky, musical), irradiation, dependence from the body position,
I point ( mitral valve) : loud crescendo & long
II point (aortic valves): loud intense and long
10
III point (pulmonary valve): loud rumbling and short
IV point (tricuspid valve): short during diastole
V point : Towards the right parasternal line
Extracardial murmur: Present
pericardium frictium: No pleuropericardium friction: no
Blood pressure: assess according formula
systolic blood pressure : 110mm/Hg diastolic blood pressure 60mm/Hg ( in norm
for children older 1 year systolic min - 90 + 2 x n (n is age in years) max - 100 + 2
x n (n is age in years) diastolic:1/2-1/3 of systolic)
DIGESTIV SYSTEM
Inspection
Inspection of oral cavity: mucous membrane of cheeks, palate, gums, pharynx,
throat (color – pink, hyperemia (indicate place): Hypermic tonsils dry or moist,
tonsils : Moist
__________________________________________________________________
Tongue: coated tongue follicles, fissures, geographical tongue, covered : Coated red
tongue.
Inspection of abdomen: shape: normal and size: normal symmetrical or not,
participation in breathing: Active condition of the umbilicus: Normal visible
peristaltic present or not, hernia: No umbilical vein visuals or not: No
Examination of the perianal area: gaping anus: Normal mucosal prolapse of the
rectum: Normal fissures of the anus.
Palpation of abdomen
Superficial palpation of abdomen: soft abdomen, abdominal distension (indicate
place) : soft abdomen with no distention. muscular tenderness and rigidity: Absent
painfulness a (epigastric, right subcostal area, left subcostal area, right lateral area,
left lateral area, right iliac area, left iliac area), local infiltration (indicate place): pain
in the Epigastricum and subcostal areas.
meteorism: No
Deep palpation of large intestine:
sigmoid colon is painless or painfulness; the width: 2Cms (in normal about 1-2 cm),
soft or density, mobile or not, grumbling is absent or present;
cecum is painless or painfulness, the width is: 2 cms (in norm the size is 3-3,5 cm),
mobile or not, soft or density, grumbling is absent or present; ascending part of the
colon, transverse colon is placed: grumbling Present (in norm above umbilicus or 12 cm lower than it), painless or painfulness; the width: 2cms (in normal about 2- 2,5
cm), soft or density, mobile or not; descending part of colon: grumbling is absent or
present.
Symptom of Shchotkin- Blumberg: positive or negative.
Palpation of the liver: liver is not palpated, palpated lower than rib in 2cm, shape
of edge acute or rounded, consistency soft or density, condition of surface smooth
or nodule;
11
The palpation of spleen: spleen is not palpated, palpated lower then left rib in cm,
shape, condition of surface, tenderness);
The symptoms of gallblager (positive or negative): Ker’s: negative, Ortner’s:
negative, Murphy: negative Mussi–Georgievsky: No
Palpation of pancreas painless or painfulness in point of Desjardin: No MayoRobson: No
Abdominal percussion:
Percussion sound : tympanic; weakened, increased, absent;
Percussion of sizes of liver by Kurlov’s method ( tab.6)
Table 6
The sizes of liver by Kurlov’s method
Line of
Age of the child (years)
Patient
measurement
1-3
3-7
7-12
Over 12
Right midclavicular size
Anterior median
size
Left coastal arch
or right angel
bisector size
5cm
6 cm
8 cm
10 cm
4 cm
5cm
7cm
9cm
3 cm
4 cm
6 cm
8 cm
Free fluid in abdominal cavity (fluid wave, fluctuation are present or not)
Auscultation of abdomen: is present of grumblings or not
Characteristics of stool:
Frequency :( more then 3 day per day, 3 time per day, 3 time per week, less than 3
time per week);
consistent (type according Bristol’s stool chart, tab.7) Type2 color of feces: brown
black, impurity of feces (blood red, dark red), mucus, fat.
Table.7
Bristol stool chard
Type of stool
Characteristic
Type1
Separate hard lump, like nuts ( hard to pass )
Type-2
Sausage shaped but lumpy
Type-3
Like sausage a but with cracks on it surface
Type -4
Like or sausage or snake, smooth and soft
Type-5
Soft blobs with clear –cut edges (passed easily)
Type-6
Fluffy pieces with ragged edges, a mushy stool
Type-7
Watery, no solid pieces
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URINAL SYSTEM
Diuresis:
urination
rate
____normal__________________________________________ (ratio day time
and night time, in norm 2:1), volume of urine__normal______________ (1-10 years
– V=600 + 100 (n-1) n – is age in yr., more than 10 years -1500 ml), volume of
single act of urination___80 ml________1500ml____________________ (tab.8),
painful
difficult
urination___no__________________________________
involuntary
urination____no_____________________________________________.
Table 8
Average volume of single act of urination
Age
Volume in ml
5 years
100
6-10 age
150
Senior school age
250
Patient
Bimanual palpation of kidneys: are palpated or not, palpation suprapubical part of
abdomen:
painless
or
painfulness)___painless____________________________________
__________________________________________________________________
Pasternatsky’s symptom negative or positive, one the one or both sides)
ENDOCRINE SYSTEME
Palpation of thyroid gland: enlargemed or not : Enlarged surface smooth or nodule,
consistency soft or nodule, painless or painfulness
Estimation of sexual development:
in girls: Ax :0 Р : No Ма : No Ме: No
Menarche with __________ years
in boys: Ax ____ Р _______ F ________ L _______ V ________
Formula for estimation of sexual development in girls:
Ax : No Р : No Ма: No Ме: No
Ax (axilla)- growth of hair in the axilla
P (pubic) - pubic hair
Ma – development of mammary glands
Me - becoming the menstrual function: Me 0 - no menstruation, Me 1 - 1-2
menstruation at the time of examination, 2 - irregular menstruation, 3 – regular
menstruation
Formula for estimation of sexual development in boys:
Ax ____ Р _______ F ________ L _______ V ________ ❌
13
Ax (axilla)- growth of hair in the axilla
P (pubic) - pubic hair
F (face) – growth of hair on the face: F0 – absence of hair on the face, F1 - pilosis
on the upper lip, F2 - coarse hair on the upper lip and the appearance of hair on the
chin, F3 - a common hair on the upper lip and chin, the beginning of the growth of
whiskers, F4-5 - fusion zones pilosis
L (larynx) - the growth of the thyroid cartilage: L0 - no signs of growth, L1 protrusion of the cartilage begins, L2 - distinct protrusion (Adam's apple).
V (voice) - changes in voice: V0 - child's voice, V1 - mutation of the voice (voice
cracking), V3 - male timbre of voice.
VI. PRELIMINARY DIAGNOSIS
Curator must choose the complaints, information from history diseases, past history,
pathological finding during physical examination and make preliminary diagnosis
On the base of patient’s complaints (list them)
__coughing,pain,_speech_problem,_fever,_pain_in_back,_weakness,headache
chest pain _,abnormal sleep ,fatigue tension urination abnormal ____
on base of information from of history diseases (write them) _____after treating
pneumonia it appeared again and become more severe and turns to form bronchitis
.____________________________________________________________
on base of past history (write them) _past history of asthma ,living condition is
not good .lives in polluted area , allergy with pollens which leads to pnemonia
which further leads to acute bronchitis .________
On base of objective examination (list all abnormality symptom)
_1) Distant heart sounds observed.
2) Diminished breath sounds.
3,) Hyperinflation.
the preliminary BASIC DIAGNOSIS can be suspected
A physical examination will often reveal decreased intensity of breath sounds, wheezing, rhonchi, and prolonged expiration. Most physicians rely
on the presence of a persistent dry or wet cough as evidence of bronchitis.
CONCOMINAT DIAGNOSIS CAN BE SUSPECTED
A comcomitant can only br made the oxygen levels in your blood or by calculating
yhe functional capacity of the lung via chest X rays and blood test
preliminary so the patient had acute bronchitis.
VII. PLAN OF ADDITIONAL INVESTIGATION
Choose laboratory and instrumental methods of investigation, which are
necessary for conformation of the clinical diagnosis, and those which are obvious
for all patients:
1. Complete blood analysis,
2. General examination of urine,
3. Feces analysis on the helminthes eggs
4. Analysis on enterobiosis
14
Prescribes additional laboratory and instrumental investigations of different system
corresponding to suspected diseases:
Respiratory system: blood test for estimation immune system: IgE, IgA, IgM, IgG,
T-, B- lymphosytes, X-ray investigation of lung, bronchoscope, functional
respiratory test (spirography, pneumotachmeter, peak flow meter), analysis of
sputum, analysis of pleural punctuate; consultation of ETN specialists,
immunologist.
Cardiovascular system: biocemical blood test (proteins, lipids, electrolyte balance,
blood coagulation test, antistreptolysin- O titer ( ASO titer), C-reactive protein (high
sensitivity), presence in blood LE-cells, immunologic examination, measurement of
blood pressure, electrocardiography, phonocardiography, ultrasound examination
of heart, doplerography, roengenography of chest and joints, contrast angiography,
biopsy skin, synovial capsule of joints, rheumatoid nodules.
Digestive system: stool test (coprogram), bacteriological investigation of feces,
occult blood feces analysis, elastasa-1, test biochemical blood tests:
blood analysis on liver function (bilirubun’s, protein’s changing, AlAt, AsAt;
fibrinogen, protrombin; determination serum markers of hepatitis B and C; pancreas
enzyme level blood test, glucose; determination urine amilasa level; presence a bile
pigments in urine: pH meter, esophagogastroduodenoscopy with folloing
determination H. Pylory, rectoromanoscopy, colonoscopy, irrigography, ultrasound
diagnostic of liver, pancreas, gallblager, computer thomography,
Urorenal system: renal function blood test (urea, creatinin, rest nitrogen);
Nechyporenko urin test, Zimnytsky urine test, bacteriological investigation of urine,
retrograde pyelography, ultrasound investigation of kidneys, urine bladder, contrast
rengenography of kidneys, computer thomography, cystoscopy.
Blood system: general blood analysis with counts of reticulosytis, determination of
osmotic resistances of erytrosytes, determination of hematocryt, examination of
blood coagulation, cloth retraction, counts trombosyts, prothrombin and heparin
index, coagulogram, tromboelastogram, ultrasound investigation of liver and spleen,
sternal punction, roentgengoraphy of bones, lymphatic nodes punctuation;
consultation of hematologist.
Endocrine system: hormones blood level concentration (for example hormones of
thyroid glands); glucemic profile, examination of urine sugar content, 17ketorsteroid concentration,
examination of basal metabolism, ultrasound
investigation of thyroid gland, suprarenal gland, ovariec, roentgenography of skull,
a skeleton, roentgenography of Turkish saddle; consultation of endocrinologist.
Nervous system: electroencephalography, ultrasound investigation of brain,
computer tomography, consultation of neurologist.
Assessment of laboratory investigations
The results of additional investigations (with interpretation):
Clinical blood test (CBC)
RBC__normal ______Hb__11 gram/dl
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WBC increased Neutrophils: Rised band segm__ eos____increased __
lymph__________ mon______ESR: Rised
PL __rised
Conclusion _as it is seen from the blood test the amount of wbc and neutrophil is
abnormal _,in her past history she had asthma due to which her immune system
was not strong _,and also she had inflammation which lead to coughing for long
days and lead to acute bronchitis. _____________________________
Clinical urine test
Amount ___normal __Gravity
___normal_____Ph____acidic___Protein______no___Glucose ____no___
Ketones ___no_____Epithelium _pale yellow skin colour___________________
Leucocytes____raised___Erythrocytes_____normal___Casts______absent____
Crystals ___absent_______
Mucous ______absent ____Bacteria ______absent_________
Conclusion :
Urine test corresponds to normal value . _
_Treatment :
humidifier, breathing in steam, and drinking plenty of liquids like water or
broth,eliminate irritants ..
Amoxicillin is generally considered the first-line treatment for bronchitis
Acetaminophen or ibuprofen for fever and mild pain.
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