PEOPLE’S FRIENDSHIP UNIVERSITY OF RUSSIA

FACULTY OF MEDICINE

DEPARTMENT OF PEDIATRICS

HEAD OF DEPARTMENT- Проф. КУЗМЕНКО Л.Г.

STATUS PRESENCE
NAME OF PATIENT: ПЕТРОВИЧЕВА ТАТЬЯНА СЕРГЕЕВНА

Преподаватель:Асс.Доцент КУТАФИН Ю. Ф.

Сura
tor- Deepankar Srigyan

Group- ML 511

MOSCOW 2008
Full name of Patient: Petrovicheva Tatyana Sergeevna
Age (date of birth): 13 yrs (02-04-1995)
Nationality: Russian
Date of admission: 04-11-2008 at 11 AM
Date of starting of curation: 12-11-2008 at 12AM

Clinical Diagnosis: Congenital Heart Defect

STATUS PRESENCE
General state: satisfactory
Position of the patient: active
Body Constitution:
Parameters: In normal- Of patient-
Body height 153 cm. 163 cm.
Body weight 34-36 kg. 38 kg.
Circumference of 55 cm. 55 cm.
head
Circumference of 69 cm. 65 cm.
chest

Physique(body build): asthenic.

Skin: dry, pale-pink, with itching shade on upper & lower limbs.
Subtaneous fatty layer: moderate & equal development.
Turgor of the tissues: normal satisfactory; no oedema; normal
elasticity of skin.
Lymphatic nodes: mandibular lymph nodes are palpable, 4-6 in
numbers, with low consistency & free mobility, low sensibility.

Muscular system: moderate development, tonus & force normal.

Skeletal system:
skull well developed,fundicular constitution:Size- 55 cm.,skull
sutures stabilized.
Thorax: closer to cylindrical form, deformed at xiphoid process of
sternum. Vertebral column: presence of scoliosis at
thoracic vertebral column.
Extremities: unchanged, left side shoulder down.
Joints: unchanged, free movements of joints.

Respiratory system:
Type of respiration: thoracic; nasal respiration free, no discharge
from nose. Respiratory rate- 20 per min.
Voice: clear, Cough: dry, Respiration: equal but difficult(dyspnoea)
on physical heavy work. Vocal tactile fremitus not changed;
Bronchophonia(vocal resonance) not changed.
Lungs:On comparative percussion- pulmonary/clear percussion note
over the entire surface.
Lower borders of lungs : In Normal-

Lines Right Left

Midclavicular line 6th rib Lower border of left
lung along the
midclavicular line
remarkable away
from sternum at
height of 4th rib and
sharply goes down.
Mid-axillary line 8th rib 9th rib
Scapular line 9th -10th rib 10th rib
Paravertebral line At the level of At the level of
spinous process of spinous process of
11th thoracic 11th thoracic
vertebrae. vertebrae.

Lower borders of lungs : In Patient-

Lines Right Left

Midclavicular line 6th rib Lower border of left
lung along the
midclavicular line
remarkable away
from sternum at
height of 4th rib and
sharply goes down.
Mid-axillary line 8th rib 9th rib
Scapular line 10th rib 10th rib
Paravertebral line At the level of At the level of
spinous process of spinous process of
11th thoracic 11th thoracic
vertebrae. vertebrae.
Mobility of lung’s borders: 0.5-1.0 cm.

Character of breathing: vesicular breathing, dry rales.

Circulatory organs:
Visible chest deformity at lower sternal region, postoperative scars
present; Vessels of neck are not visible but jugular veins are
palpable. Apex beat heard at
5th intercostal space 0.5 cm. inside from midclavicular line.
Borders of absolute dullness of heart:
Borders: In normal- In patient-
Upper 4th rib 4th rib
Left Between Between
midclavicular & midclavicular &
parasternal line, parasternal line.
nearer to parasternal
line.
Right Left border of Left border of
sternum. sternum.

Borders of relative dullness of heart:

Borders: In normal- In patient-
Upper 3rd rib 3rd rib
Left 0.5 cm inside from On midclavicular line.
left midclavicular
line.
Right Right border of Right border of
sternum sternum
Apex beat 0.5 cm inside from On midclavicular line
left midclavicular line at 5th intercostal
at 5th intercostal space.
space.

Tones: noisy and rhythmic.

Sound: systolic murmurs at apex on midclavicular line at 5th
intercostal space.

Pulse: rhythmic, frequent, uniform. Pulse rate- 90/min.

Arterial blood pressure: 110/70 mmhg.
Digestive organs:
Lips: pink, moist; Tongue: clean, moist. Buccal mucosa and gums are
healthy; Oro-nasopharynx is clear, tonsils are normal; Number of
teeth- 28 are permanent,clean & healthy.
Abdomen symmetrical, oval shaped,scars absent.
State around the umbilical region: hernias absent.
Appetite normal, eating 3-4 times in a day.
Liver is palpable 1 cm below the costal margin, dense, smooth,
absence gravity of pain.Spleen is not palpable.
Stool: frequency- 1 time in a day, formed, soft consistency, brown
colour, without tenderness of defaecation, condition of rectum is
good.

Urogenital system:
Type of urinary passage- free, 5-6 times in a day.Pasternsky's
symptom absent. Urine: light yellow color, full transparent; Specific
gravity of urine- 1020.
Development of sex organs: SMR Stage(Sexual maturity rating)- 3,
Breast and areola enlarged,no contour separation; pubic hairs
appeared and secondary sexual signs are well visible.

Neurological and endocrine system:

Sense organs: eyes- good visual acuity, good condition of
conjunctiva and pupil. Ears- good audition, the condition of pinna &
external meatus is good. Conciousness clear, good
intellect, good mood & clear speech.Sensitivity of tactile, painful and
temperature is normal. Pathological reflexes (hyperkinesias,
tremors) are absent.
Condition of endocrinal glands is good.

THE LITERATURE USED:

1. Essential pediatrics,6th edition by O.P.Ghai, Piyush Gupta and
V.K.Paul, CBS Publishers, India,2008.
2. Детские Болезни:Учебник,часть-1,Тюрин Н.А., Кузьменко Л.Г.,
М.:Изд-во РУДН,2004.-610 с.
3. Class materials given by Асс. Доцент КУТАФИН Ю. Ф. And
Контемирова М.Г. , РУДН.
4. Tsepova E.L. Recording patient’s case report (information book for
the third year foreign medical students). – Smolensk: SSMA, 2004.
– 58 p.
5. Macleod’s Clinical Examination // Edited by John F. Munro, Ian W.
Campbell / Tenth edition. – 2000. – 312 p.