Danylo Halytsky Lviv National Medical University

Department of Pediatrics No. 2

Guidelines for student individual work

Academic Year 5th

for specialty 222 "MEDICINE"

Topic: “Guideline for writing the case report for 5-year

medical students”

Hours: 2

Approved at the Meeting of the Department

Protocol No.1 of “29” of August 2022

Lviv – 2022
 DANYLO HALYTSKY L’VIV NATIONAL MEDICAL UNIVERSITY
Department of Pediatrics No. 2

Department Head
Prof. L. Besh

Tutor
___________________

Guideline for writing the Learning Medical Record

for 5-year medical students

Patient’s name: ________________________________________________________________________

Patient’s diagnosis: _________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

_________________________________________________________________________

Patient’s age: _________________________________________________________________________

Submitted by

________________________

Group No.___, 5-year student

Lviv – 2023
I. NEWBORN IDENTIFICATION
Baby ____________________, sex, date, place, and time of birth

II. HISTORY
Prenatal information: Maternal age, gravidity, parity, # of abortions, living children, EDC, LMP
Prenatal care: Blood type. Coombs, serology, other blood tests, pelvimetry, screening tests
(e.g., GTT; special studies on amniotic fluid, urine, or blood), GBS status if
known.
Prenatal complications:
1. Pre-existing diseases - C.V., respiratory, GI, GU, CNS, endocrine, psychiatric.
2. Pregnancy-related diseases - anemia, diabetes, toxemia, infection (syphilis, GC,
candidiasis, TR, UTI, viral).
3. Exposure - drugs (narcotics, antibiotics, hormones), blood products, X-Rays, viral
exanthems.

Previous pregnancies: Year of birth (age), sex, prenatal complications, type of delivery, birthweight,
pregnancy outcome
FAMILY HISTORY
Marital status of mother
Father: Age, general health, same father for previous pregnancies?
Siblings: General health, congenital malformations?, chronic diseases?

DELIVERY:
Gestational age: 30 wks
Onset of labor: Spontaneous or induced?, method of induction
Membranes: Ruptured spontaneously or artificially?, rupture/delivery interval, polyhydramnios?,
oligohydramnios?
Medications during labor and delivery particularly antibiotics for GBS prophylaxis
Fetal presentation
Duration: 1st stage, 2nd stage, 3rd stage
Method of delivery/indication for method
Complications (maternal): Episiotomy, laceration, hemorrhage, fever, GBS status
Complications (fetal): Fetal monitoring (heart rate, decelerations), cord prolapse, abruptio placenta,
placenta previa, meconium staining of amniotic fluid
Resuscitation: Oxygen, bag and mask, intubation and PPV, drugs, Apgar scores (1 and 5 minutes
or extended as needed)
Post-delivery care: Erythromycin, Vitamin K1 IM, cord blood sent for serology, Coombs, blood
group and Rh, bilirubin (optional), passage of meconium and urine noted
Birth weight: 1100 gm Birth length: 27 cm
NEONATAL COURSE (problems of transition, diseases, diagnostic and treatment measures,
treatment effectiveness).

III. CURRENT PHYSICAL EXAMINATION

Age: 24 hrs after delivery
 Measurements: Temperature, RR, HR, SpO2, weight, head and chest circumference,
length, percentiles
Skin: Cyanosis, pallor, jaundice, milia, birthmarks, rashes, nevi
Head: Fontanelle, sutures, caput, abnormalities, molding cephalhematoma
Eyes: Lids, discharge, lens, pupils, red reflex, abnormalities
Ears: Pits, tags, low set or rotated, abnormal pinna
Nose: Patent airway, congestion, discharge
Mouth: Lips, teeth, tongue, frenulum, uvula, cleft lip, cleft palate
Neck: Sinuses, torticollis, masses
Chest: Symmetrical shape, breasts, abnormalities, precordium, apical impulse, heart murmur
Lungs: Respiratory rate, retractions, RDS score, grunting, breath sounds (asymmetrical, rales,
ronchi, wheezes).
Nasal cannula O2, CPAP, Mechanical Ventilation
Heart: Heart sounds/Rhythm/Murmur
Pulses
Abdomen: Distended/Scaphoid, umbilicus (2-vessel cord?), hernias, liver, spleen, kidneys, bowel
sounds, other masses
Extremities: Edema, polydactyly, femoral pulses, syndactyly
Skeletal system: Fractures, hip dislocation, sinuses, vertebrae, spinal dysraphism.
Neuromuscular: Conciseness (lethargy, stupor, coma), tone, paralysis, twitching; cranial nerve/
brainstem functions (Doll’s eyes, gag, etc); seizures.
Reflexes: Moro, tonic neck, stepping, placing, rooting, sucking, plantar and palmar grasp
Genitalia:
Male: Penis, scrotum, testes, hydrocele, hypospadias, torsion
Female: Labia, clitoris, discharge, imperforate hymen
Anus: Patent, meconium, abnormalities (imperforate, abnormal position).

IV. IMPRESSION/ASSESSMENT (preliminary clinical diagnosis based on the data

above and it’s substantiation)
RDS III stage. IVH grade III. Prematurity 30 wks.
Substantiation…

V. MANAGEMENT PLAN of the all identified clinical problems including

investigation, treatment, and detailed feeding administration with all
calculations
 Appendix 1
PATIENTS’ DATA

Student # 1
Gestational age: 30 wks
Birth weight: 1100 gm Birth length: 27 cm
Current physical examination age: 24 hr after delivery
Preliminary clinical diagnosis: Severe RDS. IVH grade 3. Prematurity 30 wks.

Student # 2
Gestational age: 38 wks
Birth weight: 3800 gm Birth length: 27 cm
Current physical examination age: 36 hr after delivery
Preliminary clinical diagnosis: Rh hemolytic disease of a newborn.

Student # 3
Gestational age: 40 wks
Birth weight: 4200 gm Birth length: 55 cm
Current physical examination age: 3 days after delivery
Preliminary clinical diagnosis: Birth trauma. Subdural hemorrhage. Erb’s palsy.

Student # 4
Gestational age: 36 wks
Birth weight: 1500 gm Birth length: 43 cm
Current physical examination age: 48 hr after delivery
Preliminary clinical diagnosis: Perinatal asphyxia; HIE stage II. IUGR. Prematurity 36 wks.
Hypoglycemia.

Student # 5
Gestational age: 38 wks
Birth weight: 3600 gm Birth length: 49 cm
Current physical examination age: 2 days 12 hr after delivery
Preliminary clinical diagnosis: Hemorrhagic disease of a newborn.

Student # 6
Gestational age: 36 wks
Birth weight: 2200 gm Birth length: 44 cm
Current physical examination age: 24 hr after delivery
Preliminary clinical diagnosis: Early neonatal sepsis. Prematurity 36 wks.

Student # 7
Gestational age: 35 wks
Birth weight: 1400 gm Birth length: 41 cm
Current physical examination age: 36 hr after delivery
Preliminary clinical diagnosis: Congenital CMV infection. IUGR. Prematurity 35 wks.

Student # 8
Gestational age: 36 wks
Birth weight: 2100 gm Birth length: 43 cm
Current physical examination age: 4 days after delivery
Preliminary clinical diagnosis: Congenital toxoplasmosis. Prematurity 36 wks
Student # 9
Gestational age: 36 wks
Birth weight: 2300 gm Birth length: 43 cm
Current physical examination age: 3 days after delivery
Preliminary clinical diagnosis: Congenital Syphilis. Prematurity 36 wks.

Student # 10
Gestational age: 30 wks
Birth weight: 1500 gm Birth length: 37 cm
Current physical examination age: 20 days after delivery
Preliminary clinical diagnosis: Late Neonatal Sepsis. Meningitis. Prematurity 30 wks.

Student # 11
Gestational age: 40 wks
Birth weight: 4000 gm Birth length: 51 cm
Current physical examination age: 49 hr after delivery
Preliminary clinical diagnosis: ABO hemolytic disease of a newborn; jaundiced clinical form.

Student # 12
Gestational age: 43 wks
Birth weight: 3800 gm Birth length: 52 cm
Current physical examination age: 72 hr after delivery
Preliminary clinical diagnosis: Intrapartum asphyxia: HIE III. Postmaturity.

Student # 13
Gestational age: 29 wks
Birth weight: 1200 gm Birth length: 38 cm
Current physical examination age: 72 hr after delivery
Preliminary clinical diagnosis: RDS. PDA. Prematurity 29 wks.

Student # 14
Gestational age: 36 wks
Birth weight: 2400 gm Birth length: 45 cm
Current physical examination age: 10 hr after delivery
Preliminary clinical diagnosis: TTN. Prematurity 36 wks.

Student # 15
Gestational age: 34 wks
Birth weight: 1800 gm Birth length: 40 cm
Current physical examination age: 24 hr after delivery
Preliminary clinical diagnosis: Congenital pneumonia. Prematurity 34 wks.