Crimean State Medical University named after

S.I. Georgievsky

DEPARTMENT OF CHILDREN
DISEASES

Department of Internal Disease

Professor: - Fedoseeva Victoria Mikhailovna

PATIENT: - ANYA PLUZNUKOVA

AGE: - 12 YEARS OLD

CLINICAL DIAGNOSIS

MAIN DISEASES: -. Persistent Bronchial asthma, 2nd stage, period of

exacerbation

COMPLICATIONS: - ABSENT

ACCOMPANIED DISEASES: - NONE

Student: KOLLOJU RAGHAVI

Course: 3
Group: LA 1 CO 214(1)
Faculty: International Medical Faculty
 PASSPORT DATA

1. Full name: - Anya Pluznikova

2. Age: - 12
3. Date of Birth: - 14th June 1994
4. Nationality: - Ukrainian
5.Diagnosis: - Persistent Bronchial Asthma,2nd stage, period attack.

COMPLAINTS

The patient complains of difficulties in breathing. She suffers expiratory

obstruction every day, 7 – 8 times a day. Drugs that helps are salbutamol and
euphyline.It gets severe during physical exercises and change of weather and at
night. Patient complains of appearance of rashes on skin, buttocks and face.

CASE HISTORY (Anamnesis Morbi)

The patient had the 1st attack when she was 7 years old. Sudden onset after
physical exercise. On the 1st day, her inspiration from nose was very difficult. Disease is
acute in spring and autumn. Patient has allergy reaction to red colored food and sugar.
She is often infected by viral disease up to 5 times a year.

Anamnesis vitae

The patient had proper physical and mental development and it was on time. The
patient weighed 2 kg 750 g and was 51 cm in height. She was breast fed. At the age of 7,
she had her 1st attack of breathing difficulties. The patient often had respiratory infections
(viral). The patient has been immunized in time and according to plan. Her 1 st vaccination
was in 1st year old. The patient has an allergy to red colored food and sugar.
 1GENERAL EXAMINATION
(status presents)

The general condition of the patient is satisfactory. Consciousness is clear,

posture is active, gait is not changed, and facial expression is healthy but always sad.
Body structure is asthenic. The thorax form changed.Patient positionPatient position is
normal while nourishment is satisfactory.

Temperature of body: - 36.9 axillary

Pulse rate: 88/min
Respiratory rate :18/min
Blood pressure: 110/70 mmHg
Weight :31 kg
Height :150 cm

SYSTEMS REVIEW

(a)Skin – smooth, usual color. Absent of scar, turgor, rashes, emptions and edema.
Growth of hair in extremities is normal and without falling. Elasticity of skin is present.

(b)Mucus membrane-Under conjunctiva and nasal is pale pink while oral is pink.

(c) Nail- Normal shape and red color. Brittleness absent.

(d) Subcutaneous fat- Subcutaneous fats developed moderately. Edema is

absent.

Examination of body part

(a) Head - Her head is proportion, symmetry and correspondent to facial and
cerebral parts

(b) Face- Her face is symmetrical and has a regular shape. Distance between nose and
Mouth is normal

(c) Hair- Female type, hort. Texture is soft.

(e) Eye- Width of eye slit is moderate and normal shape. Pupils are grey color.
Vision of the patient is satisfactory and absent of exophthalmos,
Enophthalmos. Papillary size and shape normal, reaction to light present.

(f) Nose- Shape of nose is normal. Absent of discharge or any bleeding from the
Nose.

(g) Ear- Color of skin is usual and node not palpated. The Pinnas and tympanic
membrane is absent of inflammation or perforation. Hearing is
 satisfactory and reaction to sound is positive.

(I) Neck, throat- Usual shape and absent of carotid and jugular pulsation. The
Tonsils are absent of any inflammation. Epiglottis function
is normal and voice is also normal, no hoarseness or
stridor. Position and mobility of the neck is satisfactory
and normal. hyoid organ is palpable included the lymph
nodes of submandibular and cervical group. Trachea
position is symmetrical without any sign of edema.

(k)Lymph nodes- Submandibular, axillary inguinal lymph nodes are determined with the
size from 1.0 – 0.5 mm in diameter, rounded form with smooth surface, elastic
consistence, mobile, not adhered to the skin and surrounding subcutaneous fat. Painless
when palpated. The skin over them has not changed. While occipital, periauricular,
cervical, supra and sub clavicular, cubital and popliteal are not palpable

Locomotor System

The muscles are developed moderately, tone and muscle’s force are identical on both
sides. The tenderness of the extremities muscles during palpation is marked. Palpation
and tapping of the bones are painless. Joints are of regular shape, painless during
palpation and movements. Active and passive movements in joints are full.

Respiratory system

The patient has abdominal type of respiration. Breathing is deep and rhythmic.
Expiration and inspiration are not equal. My respiratory rate is 18.

From the palpation, the vocal fremitus was identical and resistance of chest
moderate.

The lower borders of the lungs were determined by topographic percussion.

Line Right lung Left lung

Parasternal 5th intercostals ----

space
Midclavicular ----
6th intercostals
Ant.axillary space 7th intercostals
space
Midaxillary 7th intercostals
space 8th intercostals
Post. Axillary space
8th intercostals
space 9th intercostals
 Scapular 9th intercostals space
space
Paraspinal 10th intercostals
th
10 intercostals space
space
11th intercostals
th
11 intercostals space
space

Upper borders of the lung:3cm above clavicle fr right and left borders.

Topographic Thoracic excursion of lower lung borders; -

Line Right lung Left lung

Midclavicular 4-6 cm --

Mid. Axillary 6-8 cm 6-8 cm

scapular 4-6 cm 4-6 cm

From auscultation of the lungs, you can hear many dry rales and inspiration
longer than expration.Inspiratory from nose is difficult.

Bronchial breathing also was heard in the area of larynx, trachea and 2/3
intercostal space, also anteriorly over the manubrium sterni,at the point of its junction
with the sternum and posteriorly in the interscapular space at the level of 3 rd and 4th
thoracic vertebra.

From percussion examination, the comparative percussion – bandbox sound,

Traube’s space give tympani's sound during percussion.

Cardiovascular system

Visible arteries pulsation is absent. Venous pulse is negative, Cardiac humpback

and visible pulsation in the heart region is absent.

Apex beat is palpated in the VI intercostals space,1cm lateral to Left midclavicular line
with width 2cm in diameter. The pulse is locales, height is normal, strength moderate,
shape domed. Cat’s murmur was not determined. Epigastric pulsation in breathing is
palpable, in deep inspiration it is determined weakly.

The right and left borders of vascular dullness are found along the edges of the
sternum, but the left vascular bundle displace slightly outside to edge of sternum.

On auscultation of the heart, two sounds are heard in all the points. The sounds
are not rhythmic, slightly strong, and dome shape. The second sound is louder than the
first one on the heart base. Cardiac rate is 75 per minute.

Arterial pressure: systolic – 110 mm Hg, diastolic – 70 mm Hg

1.1.5 Digestive system

The tongue is of the usual size, moist, coated and clean. The mucous of mouth is
light pink color. Tonsils are absent. Most teeth are still present with absent of each one
molar teeth upper right and lower left jaw.

Abdomen is of a regular form, symmetric. The abdominal wall participates in

breathing. A dull sound is heard over all parts of the abdomen during percussion. In
superficial palpation, abdomen is soft and painless. Hernias and superficial tumors are
absent. Shchetkin-Blumberg’s symptom is negative

Intestine

Surface palpation: on surface palpation the abdomen is soft and no pain reveal.
Deep palpation:

1. sigmoid is palpable in the left inguinal region as a smooth firm cylinder

2cm in diameter, it is painless, does not produce rumbling sounds, tight-
elastic consistency and mobile.,

2. Caecum is palpable in the right iliac region as a smooth, soft, painless

cylinder with diameter 3cm and mobile.

3. A descending colon is palpable in the left lumbar region with elastic

cylinder, diameter 3-4cm, painless and with limited motility.

4. ascending colon is palpable in right lumbar region with elastic cylinder,

diameter 3-4cm, painless and with limited motility.

5. transverse colon is palpated as soft, cylinder with diameter 2-3 cm without

rumbled.

On auscultation of the abdomen, peristalsis of the intestine is of moderate sound

and frequency is heard. Vessel murmurs are absent.
Stomach

The greater curvature of the stomach is determined as a soft smooth ridge 3cm
above the navel, it is painless, displaces on 1.5-2.0cm, produces slightly rumbling sound.
Other parts of the stomach are not palpable.

Liver

Liver is palpable on 1cm below of rib of arch along Linea midclavicular is, edge
is soft-elastic, equal, painless and easily tucked

Gall bladder

Gall bladder is impalpable.

Pancreas

Pancreas is not palpable. Tenderness in the points of conforming to the head, to

the body and to the tail of pancreas and in points of phrenic nerve and Costo-vertebral to
the left is not determined. The morbidity in tender points and hyperesthesia in the zones
of Zakharyin-head is absent.

Spleen

Spleen is not palpable. Borders of the splenic dullness are situated

1 Upper- at level of the IX rib

2 Lower- at level of the XI rib

Sizes of the splenic dullness are

1 Transverse- 5cm

2 Vertical – 6cm

Urinary system

Kidneys are palpable. Palpation of the right kidney’s region is painless. The full
kidney is palpated, beans-like form with smooth surface elastic consistence length about
11cm and traverse size about 5.5cm. a while left kidney not palpable. Palpation along the
course of ureters is painless. Pasternatsky’s symptoms are negative on both sides. The
urinary bladder is not palpable. Palpation of the ureters and appendages region is
painless.

Endocrine System

Changes of the eyes (exophthalmos or enophthalmos) are not determined. The

thyroid gland is not enlarged. Its isthmus is palpated as soft. Painless band 1cm diameter.
 Nervous system and psychic state

The patient is fully competent in place and time, quiet. Speech is correct,
elocution. Thinking is logic. Gait is regular. Paresis and paralysis are absent. Pupils are
identical size, react to light. Nystagmus absent.

ADDITIVE TEST

Urinalysis

Color – yellow
Specific gravity – 1010
Reaction – slightly acid
Protein – 0.33g/l
Transparence- clear
Bilirubin- not revealed
Glucose – not reveal
Urobilin- negative
Aceton- negative
PH – carbon

Microscopy of urine sedimentation:

Squamous epithelium- 1-2 in field vision
Erythrocytes – 0 in field vision
Leucocytes – 12 in f. v

Casts:
Hyaline - not revealed
Granular - not revealed
Salt- not reveal
Mucus - not revealed

Bacteria - negative
Renal epithelium- not revealed

Conclusion: - leukocyturia indicates inflammation in kidneys or

Urinary tracts.

NEPHIPORENKO’S TEST

Leucocytes 3.75 X10 liter

Erythrocytes 1.25 X 10 liter

Conclusion: normal
 Blood analysis

Erythrocytes – 4.3x 1012 /L

Hemoglobin – 134 g/L
Leucocytes – 4.4 x 1012/L
Basophils – 0%
Eosinophilic- 2%
Stab neutrophils – 2%
Segmented neutrophils – 52%
Monocytes – 10%
Lymphocytes – 34%
ESR- 4mm/h
Color index-0.93

Conclusion: - blood count is normal

Peak Flow Metry

Time of the day Volume Date

M 3.10.2006
E 30
M 20 4.10.2006
E 25
M 20 5.10.2006
E

FINAL DIAGNOSIS

The findings of the additional investigation of the patient: the

Main disease: Persistent bronchial asthma, 2nd stage, period of exacerbation

Complications: - Absent

Accompany disease: -. None

TREATMENT

(a) Regime: - Free regime

(b) Diet: - Diet №4
Feeding: - 3 times a day

Forbidden products: red and sweet food or drinks.

Recommendation: - an allergy-free environment, maintain hygiene.

(c) Medication: Ventolin 1dose twice a day

Chlorite 5mg 4 times a day
AE vitamin 1 Drage once a day
Ketotifen 1 tablet twice a day / drops thrice a day
Inhalation of hydro cortisol once a day
Spilotherapy .

Plan of examination:

 Sugar level in blood

 Fecal entero-bios
 Eosinophils mucous from nose
 Spirogram
 ECG
 X – ray
 Oculist
 Allergy test