Plan and rules of case history registration

Plan and rules of case history registration. Anatomical and hystologycal construction of mucous membrane of oral cavity.

 

 

Oral cavity – normal anatomy. Structure of oral mucouse membrane.

The oral cavity sits at the opening of the digestive tract and is bounded by the lips anteriorly (Fig. 1.1). The vermillion zone serves as the transition area between the moist oral mucosa and the skin of the face. The oral structures are adapted to serve a variety of functions, including maintenance of a protective barrier, initia­tion of digestion, special taste sensation, speech and swallowing, immunologic defense, and provision of salivary lubricants and buffers.

1.2   Surface Landmarks

 

The oral cavity can be subdivided broadly into three areas consisting of the vestibule, oral cavity proper, and oropharynx (Fig. 1.2). The vestibule is the space that is present between the lips or cheeks lat­erally and the dentition medially. The oral cavity proper lies inside the dental arches and is bounded posteriorly by the anterior pillar of the fauces, or palatoglossal arch. Theoropharynx lies posterior to the palatoglossal arch, and includes the posterior one-third of the tongue, palatine tonsils, soft palate, and visible posterior wall (Fig. 1.3). The palatine tonsils sit in an alcove between the anterior (palato-glossal) and posterior (palatopharyngeal) arches, or pillars, and frequently exhibit surface pits or depressions called crypts (Fig. 1.4).

The retromolar trigone is a roughly triangular area behind the last molars representing the poste­rior aspect of the vestibule (Fig. 1.5). Adjacent to this is the pterygomandibular raphe,which indi­cates the junction between the buccinator and supe­rior constrictor muscles, and is used as a landmark for administration of intraoral local anesthesia. The parotid papilla, which houses the opening of

Stenson duct of the parotid gland, is located in the buccal vestibule opposite the maxillary second molar (Fig. 1.6).

 

 

 

 

 

Folds of mucosa in the midline maxillary and man­dibular labial vestibules can be seen anchoring the lips to the alveolar mucosa or gingiva, and are known as the labial frenula (Figs. 1.7 and1.8). These can be quite prominent in some cases and even affect tooth eruption.

 

Oral Mucosa

The lining of the oral cavity serves a variety of func­tions, including protection, sensation, and secretion, and is histologically adapted to the unique environ­ment inside the mouth. Oral mucosa lacks the appendages seen in skin, although sebaceous glands can be found in the upper lip and buccal mucosa in approximately 75% of adults (see Chap. 2). Submucosal minor salivary glands are found throughout the oral cavity, with highest concentra­tions in the palate and lower lip. Aggregates of lym-phoid tissue can also be found in the oral cavity, however, the largest collection of lymphoid tissue is seen posteriorly and known as Waldeyer ring.This consists of the palatine, lingual, and adenoid (pha-ryngeal) tonsils, and virtually encircles the entrance to the oropharynx. Small nodules of accessory tonsil tissue are often seen on the posterior wall of the oropharynx and may become enlarged with inflam­mation or infection and mistaken for a suspicious mass. Normal pits and depressions in tonsil tissue (tonsillar crypts) may become plugged with keratin or other debris and form cysts which appear yellow to white in color (Figs. 1.4 and 1.9). The majority of the oral cavity is lined by soft, moist, pliable, nonkeratinized mucosa which is loosely attached to underlying tissues and exhibits some mobility. This

 consists of a stratified squamous epithelium which con­tinually renews itself by division of progenitor cells in the deeper basal layer (Fig. 1.10). New cells show pro­gressive maturation as they migrate to the surface lay­ers, which are subsequently shed. Areas of the mouth that receive a greater degree of masticatory stress, namely the hard palate, tongue dorsum, and gingiva, are lined with keratinized mucosa, giving more protection against friction and abrasion This tissue is more firmly attached to the underlying periosteum, which prevents damage from shearing forces.

The mucogingival junction, where the mobile mucosa lining the vestibule and floor of mouth joins the tightly adherent gingiva of the dental alveolus, should be easily visible in the healthy state. The gingiva appears paler pink secondary to decreased visibility of underlying blood vessels through the relatively opaque keratin layer. The gingival margin should be well defined with slightly rolled margin and pointed interdental papillae. Healthy tissue will exhibit stippling, representing collagen fibers attaching the gingiva to the underlying perios­teum (Figs. 1.7, 1.8, and 1.11).

 

Fig. 1.10 Normal stratified squamous epithelium. The basal cells are cuboidal and abut the basement membrane. The shape becomes more flattened (squamoid) as the cells mature and move toward the surface. Irregularly shaped spinous, or prickle, cells are present in the intermedi­ate layers. Surface keratin keratin is also present in this diagram. The connective tissue layer below the basement mem­brane contains blood vessels, lymphatics, fatty tissue, fibrous and elastic tissues, bone, and muscle

 

Tongue

The tongue is divided into the oral tongue (anterior two-thirds) and tongue base (posterior third) by the circum-vallate papillae, which form a v-shaped line anterior to the foramen cecum(Fig. 1.12). The foramen cecum is a shallow depression which exists as a developmental remnant of the thyroglossal duct. The oral tongue is typically subdivided into four areas: tip, lateral sur­faces (sides), dorsum (top), and ventral (undersurface).

Embryologically, the mucosa lining the anterior portion of the tongue arises from the first branchial arch, and carries with it the trigeminal nerve. The mucosa of the tongue base arises from the third arch and is innervated by the glossopharyngeal nerve. The intrinsic muscles of the tongue are derived from the occipital somites, and are supplied by the hypoglos-sal nerve. Lingual tonsil tissue is frequently seen on the surface of the tongue posterior to the circumval-late papillae and lining the vallecula, which is a val­ley-like depression separating the tongue base from the epiglottis. Mucus glands are present posteriorly, and open into the crypts of the lingual tonsil.

The epithelium lining the tongue dorsum is spe­cialized to withstand masticatory trauma as well as receive taste sensation. The dorsum dorsum has an irregular, bumpy, surface secondary to the presence of papil­lae. Although some taste receptors (taste buds) can be found in the soft palate and pharynx, the majority are located on the lingual papillae. Numerous small, hair-like, keratinized, filiform papillae cover the anterior surface of the tongue dorsum and do not contain taste receptors. These projections provide an abrasive surface that helps break down food against the hard palate during mastication. They are interspersed with fewer numbers of larger, smooth, and more rounded nonkeratinized fungiform papil­lae, with taste buds present on their superior sur­face. The fungiform papillae frequently appear deeper red in hue compared to the filiform papillae,as the color of the underlying vascular core is transmitted prominently through the epithelium (Fig. 1.13). Foliate papillae are ridge-like structures on the posterolateral aspect of the tongue containing taste buds on their lateral surfaces, and are often mistaken for abnormal tissue on oral exam. . They vary greatly in size, and are virtually absent in some patients (Fig. 1.14). The circumvallate papillae are large round structures on the posterior tongue dor-sum which also house taste buds. These are usually not appreciated on exam unless the tongue is pro­truded, and are also sometimes mistaken for pathol­ogy (Fig. 1.13).

 

The lateral and ventral surfaces of the tongue, as well as the floor of mouth, are lined by thin, smooth, nonkeratinized mucosa that is fairly translucent (Fig. 1.15). Veins along the ventral surface of the tongue are easily visualized through the mucosa and can be quite prominent. A fringed fold of mucosa, called the plica fimbriata, sits lateral to the midline on each side and frequently contains tissue tags that can be mistaken for pathology. The sublingual salivary glands can be palpated laterally and frequently will be seen to bulge into the floor of mouth. The main sublin­gual duct joins the submandibular (Wharton) duct to empty into the oral cavity at the sublingual papilla near the base of the lingual frenulum. Additional tiny ducts open from the sublingual gland directly into the over­lying mucosa.

 

Palate

 

The palate forms the roof of the oral cavity and is divided into the hard palate anteriorly and the soft palate posteriorly (Figs. 1.16 and 1.17). The muco-periosteum of the hard palate is tightly bound and immobile, which explains why dental injections into this area are especially painful. The midline incisive papilla anteriorly indicates the opening of the incisive canal, which transmits the sensoryneurovascular bundle exits its bony fora­men under the mucosa opposite the maxillary sec­ond molar, innervating the posterior hard palate. The maxillary tuberosity can be palpated posterior and lateral to this behind the last molar, as the broad posterior extent of the maxilla.

 

 

 

 

Dentition

The tooth containing portion of the oral cavity is divided into maxillary and mandibular dental arches (Fig. 1.18). These are each further divided in half by the midline into quadrants. The teeth sit within the raised, alveolar (tooth bearing) bone of the dental arches. The adult, or secondary, dentition consists of 32 teeth, with 3 molars, 2 premolars (“bicuspids”), 1 canine (“eye tooth” or “cuspid”), and 2 incisors per quadrant. Molars and premolars are referred to as posterior teeth; canine and incisors are anterior. The pediatric, or primary, dentition contains a total of 20 teeth, with 2 molars, 1 canine, and 2 incisors per quad­rant. The premolars erupt into the space occupied by the primary molars, and the permanent molars erupt posterior to this as the jaws and dental arches elongate with growth. There are a variety of numbering systems used to identify each tooth. The most widely accepted method numbers the teeth from “1” to “32,” beginning with the upper right third molar (tooth #1) and proceeding clockwise across the upper then lower arches, ending with the lower right third molar (tooth #32).Each tooth consists anatomically of a root and crown, with the crown being the portion visible above the gingival margin (Fig. 1.19). The bulk of the tooth is made up of a calcified substance known as dentin,with an outer surface layer of harder enamel covering the crown and a softer material called cementum lining the root surface. The hollow inner core of the tooth, or pulp chamber, contains a soft jellylike material referred to as pulp, with nerve endings and blood vessels entering through the tip (apex) of the root via the apical foramen.The clinically visible junction of crown and root is called the cementoenamel junction, and is generally protected by the free upper edge of the gingival margin in the healthy state. Gingival recession may occur, with exposure of the softer root surface and concomitant increased risk of root surface caries, abrasion, or sensi­tivity. The tooth is anchored to the bony socket by col­lagen fibers (periodontal ligament), which can be weakened or destroyed by periodontal disease.The crown of every tooth has five surfaces, and each one is specifically named. The biting surface of a posterior tooth is referred to as the occlusal surface. The more tapered biting, or incising, sur­face of an anterior tooth is called the incisal edge. The outer, or lateral, surface of a posterior tooth adjacent to the cheek is referred to as buccal. The same surface of a more anterior tooth adjacent to the lip is labial. Alternatively, any buccal or labial surface may also be referred to as the facial sur­face. The inner, or medial, surface of a lower tooth abutting the tongue is lingual, and the same surface of an upper tooth facing the palate is palatal. The contacting surfaces of adjacent teeth are called interproximal; with the posteriorly oriented sur­face (i.e., away from midline) being distal, and the more anteriorly oriented surface (toward midline) being mesial.

 

Temporomandibular Joint

The temporomandibular joint (TMJ), where the foot­ball-shaped condylar process of the mandible articu­lates with the glenoid fossa of the temporal bone, is a synovial joint, and is located immediately anterior to the external auditory canal (Fig. 1.20). A roughly biconcave fibrocartilage disk (meniscus) is positioned within the joint space, dividing it into upper and lower cavities and allowing both hinge and gliding move­ments. The joint is enclosed by a fibrous capsule, and surrounding ligaments limit excessive joint move­ment. Dislocation of the jaw occurs when theman­dibular condyle moves anterior to the articular eminenceThe initial 10-15 mm of mouth opening occurs by hinge-like rotation of the condyle against the articular disk in the inferior joint space without movement of the disk itself or movement in the upper joint space. With wider mouth opening, the superior surface of the disk then glides anteriorly downward along the articular eminence, carrying the condyle along with it. This second

type of movement is referred to as translation. This sequence is then reversed with jaw closure.

Internal derangement of the joint can occur with destruction or detachment of the disk, in which case the disk may be displaced or dislocated (usually ante­riorly, in front of the condyle). In patients with this problem, a “click” may be present upon mouth open­ing as the condyle moves forward during translation and spontaneously recaptures the disk. This is referred to asreduction of the disk, and a reciprocal click may be noted with closure as the condyle again moves posterior to the disk. In a situation where reduction does not occur, the disk can become jammed anterior to the condyle and limit the degree of mouth opening; in severe cases this can result in a

closed lock with limitation of mouth opening.

 

 

Innervation.

Table 1.1  Cranial nerves

Number        Name    Function(s)

I                               Olfactory      Sense of smell

II                            Optic            Vision

III                         Oculomotor  Eye movement (except that mediated by lateral rectus and superior oblique muscles)

IV                        Trochlear      Eye movement (mediated by superior oblique muscle)

V                           Trigeminal    Oral/facial sensation; muscles of mastication

VI                        Abducens     Eye movement (mediated by lateral rectus muscle)

VII                     Facial           Facial sensation and taste (anterior tongue); muscles of facial expression and stapedius; and

secretomotor innervation to salivary glands (except parotid)

VIII                  Vestibulocochlear      Hearing and balance

IX                        Glossopharyngeal      Sensation and movement of pharynx; taste to posterior tongue; and secretomotor innervation

to parotid gland

X           Vagus           Main sensory and motor innervation to larynx and pharynx; taste sensation from epiglottis;

and parasympathetic supply to thoracic and abdominal viscera

XI                        Spinal accessory       Trapezius and sternocleidomastoid muscles

XII                     Hypoglossal Tongue movement

Jaws and Teeth

As first branchial arch derivatives, the maxilla and mandible are supplied by the trigeminal nerve (CN 5), which is predominantly sensory (Fig. 1.21; Table 1.1). The trigeminal (semilunar or Gasserian) ganglion is located in the floor of the middle cranial fossa and gives rise to three large nerve trunks. The ophthalmic division (V1) travels to the eye via the superior orbital fissure. The maxillary division (V2) passes through the foramen rotundum into the pterygopalatine fossa, where it receives sensory input from the maxillary alveolar bone, upper teeth, hard palate, and mucosa via the posterior and anterior superior alveolar nerves, nasopalatine nerve, and greater palatine nerve. The mandibular division (V3) exits the skull base through the foramen ovale, passes through the infratemporal fossa, and provides sensory innervation to the lower jaw via the inferior alveolar nerve (IAN), buccal nerve, and mental nerve. The IAN is encased within the bone of the mandible below the roots of the poste­rior mandibular teeth and is subject to injury during third molar (wisdom tooth) extraction.

 

 

 

Salivary Glands

There are three sets of paired major salivary glands: sublingual, submandibular, and parotid (Figs. 1.23 and 1.24). The sublingual gland is the smallest, and rests on the mylohyoid muscle in the anterolateral floor of mouth immediately under the mucosa. The secre­tions of this gland are primarily mucinous, and are therefore more viscous than saliva produced by the parotid and submandibular glands. The submandibular gland is larger and occupies the submandibular trian­gle with extension of the gland over the posterior bor­der of the mylohyoid muscle into the floor of mouth. The secretions from this gland are mixed seromuci-nous, with viscosity intermediate between those of the sublingual and parotid glands.The parotid gland is the largest of the three major salivary glands and is located in front of the ear (preauricular region), with extension to the posterior belly of the diagastric muscle inferiorly and the masseter muscle anteriorly (Fig. 1.24).The “tail” of the gland extends posteriorly under the earlobe to the sternocleidomastoid muscle (SCM). The gland is divided into superficial and deep lobes by the plane of the facial nerve (CN 7), with extension of the deep lobe to the parapharyngeal space medially. Tumors of the deep lobe may result in visible bulging within the oral cavity in the region of the tonsil, and may present as the first sign of pathology. Lymph nodes are present within the parenchyma of the parotid gland, mainly in the superficial lobe, due to incorpo­ration of lymphoid tissue into the gland during fetal development. These may present clinically as masses secondary to reactive or neoplastic processes. The parotid gland produces serous saliva, which is thin and watery compared to secretions from the other salivary glands.

There are hundreds of submucosal minor salivary glands present throughout the oral cavity (except for the gingiva and anterior hard palate), with a high den­sity notable on the soft palate and posterolateral hard palate. Secretions from these glands are purely muci-nous and represent a very small proportion of total salivary flow.

 

Innervation to the salivary glands is supplied by the autonomic nervous system, with both sympathetic and parasympathetic components. The parasympathetic sys­tem regulates fluid and electrolyte secretion, while the sympathetic system governs protein synthesis and secre­tion. The parotid gland receives parasympathetic secre-tomotor fibers from the glossopharyngeal nerve (CN 9), which synapse in the otic ganglion and then travel with the auriculotemporal branch of V3. Parasympathetic supplied from the superior cervical ganglion via the external carotid artery.

 

 

Case History

 

A detailed account of the facts affecting the development or condition of a person or group under treatment or study, especially in medicine, psychiatry, or psychology.

 

Parts:

CASE HISTORY

 

The patient:

The clinical diagnosis: 

The begining of treatment:

The end of treatment:

 The curator of III cours Student:

 

 

I.      General information about patient.

Surname and name:

Sex:

Age:

Education:

Place of employment, profesion:

Permanet adress:

Date and time of admision to the hospital:

The diagnosis at admision time:  

–     Clinical diagnosis:

–     Complication of primary disease:

 

 

2.     Patients complains.

3.     History of disease.

4.     Patient history life.

5.     General patient condition.

6.     External examination of facial region.

7.     Intraoral examination.

8.     Differential diagnosis.

9.     Clinical diagnosis.

10.   Etiology and pathogenesis of disease.

11.   Clinical conclusion.

12.   Treatment plan.

13.   Prescription.

14.   Diary:

15.   Epicrisis.

16.   Literature

 

 

Dental chart

 

To full dental chart we use Palmer Notation Method.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This tooth numbering system is simplicity itself – the mouth is divided into 4 quadrants (upper left, upper right, lower left, lower right), and teeth are numbered 1-8 going from the front tooth to the wisdom tooth in each quadrant.

 

Ministry of Public Health of Ukraine		Medical documentation Form №043/о By order of MOPH of Ukraine 14.02.2012          №110
Name of the clinic:
Dental chart №____ _____________year
First name, last name:
Male                                                Female
Birth date:
Address:
Home phone:
Diagnosis:
Patient complains:
General diseases:   Allergy:
Objective examination:

 

 

 

C – caries, F – filling, A – absent(missing) tooth, P – pulpitis, Pt – periodontitis, Cr – tooth crown, r – root, Dc – dental calculus

 

 

Bite:
Oral hygiene condition:
Condition of oral mucouse:
X-ray results:
VITA – color:
Date of oral hygiene training:
Date of oral hygiene control:
Doctors notes:
Date:	Anamnesis, diagnosis, treatment and recommendations:

 

Doctor_________________

Chief of department___________________

  

PATIENT’S CURATION AND WRITING OF THE CASE HISTORY

 

History taking

 Communication skills

 1. Communication with the patient and/or family:

•        Establish rapport with the patient and family.

•        Identify the primary concerns of the patient and/or family.

•        Recognize the triangular relationship between the physician, patient and parent and be able to communicate information to both the patient and parent, making sure both understand the diagnosis and treatment plan and have the opportunity to ask questions; be aware that the relationship changes with increasing age of the child.

•        Provide anticipatory guidance during health maintenance visits, including the newborn nursery visit.

•        Recognize the important role of the patient’s education in management of acute and chronic illnesses.

 

2. Written communication skills:

•        Write a complete summary of the history and physical examination in a timely manner which is suitable to place in the patient’s chart.

•        Outline the different formats for documenting the history and physical examination which may be used in different clinical settings.

•        Write admission orders for a hospitalized patient.

•        Write a prescription.

 

3. Oral communication skills:

•        Present a complete, well organized summary of the findings of the patient’s history and physical examination, modifying the presentation to fit the situation.

•        Communicate effectively with other health care workers, including consultants, nurses and social workers.

•        Explain the thought process that led to the diagnostic and therapeutic plan.

•        Use precise descriptions of physical findings and avoid vague terms and jargon, such as “clear” and “ARD”.

Interviewing

1. Patient interviews occur in a variety of clinical settings, including initial history for a hospital admission or first ambulatory visit, health maintenance visit, acute care visit, interim visit for a child with an acute or chronic health condition. The doctor should develop an awareness that in conducting a medical interview in a variety of settings, it is sometimes appropriate to obtain a complete medical history, while at other times a more limited, focused or interval history is appropriate. Initially, the emphasis should be on obtaining complete medical histories. Opportunities to do more focused work-ups should be available as the doctor builds competence.

2. Obtain a medical history from thesecond party (usually the parent), as well as from the patient, noting the increased reliability of obtaining information directly from the patient as the patient matures. The doctor must be aware of issues of appropriate privacy at all ages and confidentiality in older children and adolescents.

3. Obtain a relevant history that is unique to paediatrics in addition to the standard medical history.

Chief complaint

The chief complaint represents the specific reason for the child’s visit to the clinic, office, or hospital. The chief complaint may be viewed as the theme, with the present illness as the setting of this problem. Six guidelines determine appropriate recording of the chief complaint: (1) it consists of a brief statement, (2) it is restricted to one or two symptoms, (3) it refers to a concrete complaint, (4) it is recorded in the child’s or parent’s own words, (5) it avoids the use of diagnostic terms or translations, and (6) it states the duration of the symptoms.

The doctor elicits the chief complaint by asking open-ended neutral questions such as, “Tell me what seems to be the matter?”, “How may I help you?” or “What brings you here?”. Labeling-type questions such as, “How are you sick?” should be avoided, since it is possible that the reason for the visit is not because of illness. For example, the visit may be for a routine health assessment, or the chief complaint may be of a nonphysical nature.

Examples of properly recorded chief complaints for a variety of situations may be: (1) ambulatory clinic – “My child has had a runny nose and sore throat for 4 days, but today it is worse”, (2) hospital admission – “I need to have my tonsils fixed”, sore throat and repeated earaches for 5 years, and (3) health center – “We are here for a routine checkup”, last visit 1 year ago.

If the visit is for a well-child examination, one can ask, “Before we begin, is there anything of particular concern that you would like to discuss?”. This type of statement encourages the parent (or child) to bring up an issue that may not surface during routine interviewing.

Occasionally it is difficult to isolate one symptom or problem as the chief complaint because the parent may identify many. In this situation it is important to be as specific as possible when asking questions. For example, asking informants to state which one problem or symptom caused them to seek help now may help them to focus on the most immediate concern.

 

Present illness

The history of the present illness is a narrative of the chief complaint from its earliest onset through its progression to the present. Its four major components are (1) details of onset, (2) complete interval history, (3) present status, and (4) reason for seeking help now. The focus of the present illness is on all those factors that are relevant to the main problem, even if they have disappeared or changed during the onset, interval, and present.

Analyzing a symptom. Since pain is often the most characteristic symptom denoting onset of a physical problem, it is used as a prototype for analysis of a symptom. The nurse should assess pain for (1) type, (2) location, (3) severity, (4) duration, and (5) influencing factors. The type or character of pain should be as specific as possible. However, with young children, it is almost always impossible for them to describe the pain. Asking the parents how they know the child is in pain may help to describe its type, location, and severity. For example, a mother stated, “My child must have a severe earache because she pulls at her ears, rolls her head on the floor, and screams. Nothing seems to help”.

The doctor can help older children to describe the pain by asking them if it is sharp, throbbing, dull, aching, stabbing, and so on. Whatever words they use should be recorded in quotes.

The location of the pain also must be specific. “Stomach pains” is too general description. Older children can better localize the pain if the doctor asks them to “point with one finger to where it hurts”. The doctor can also determine if the pain radiates by asking, “Does the pain stay there or move? Show me where it goes with your finger“.

The severity of pain is best determined by finding out how it affects the child’s usual behavior. Pain that prevents a child from playing, interacting with others, sleeping, and eating is most often severe. It is preferable to record pain in terms of interference with activity, rather than to quote the parent’s or child’s adjectives.

Duration of pain should include the duration, onset, and frequency of attacks. It may be necessary to describe this in terms of activity and behavior, such as “pain lasted all night because child refused to sleep and cried intermittently”.

Influencing factors are anything that causes a change in the type, location, severity, or duration of the pain. These include (1) precipitating events (those that cause or increase the pain), (2) relieving events (those that lessen the pain, such as medications), (3) temporal events (times when the pain is relieved or increased), (4) positional events (standing, sitting, lying down, and so on), and (5) associated events (meals, stress, coughing, and so on).

A standard method of analyzing a symptom is listed in the following outline. These three categories – onset, characteristics, and course since onset – comprise the essential data for the present illness. Although the analysis of a symptom has concentrated on discussion of physical complaints, the same process of description and investigation can be used for emotional or psychosocial problems.

 

Analysis of a symptom

                   I.      Onset

a)          Date of onset,

b)         Manner of onset (gradual or sudden),

c)          Precipitating and predisposing factors related to onset (emotional disturbance, physical exertion, fatigue, bodily function, pregnancy, environment, injury, infection, toxins and allergens, therapeutic agents, and so on).

               II.       Characteristics

a)            Character (quality, quantity, consistency, or others),

b)           Location and radiation (of pain),

c)            Intensity or severity,

d)           Timing (continuous or intermittent, duration of each, temporal relationship to other events),

e)            Aggravating and relieving factors,

f)             Associated symptoms.

III. Course since onset

a)           Incidence

•          Single acute attack.

•          Recurrent acute attacks.

•          Daily occurrences.

•          Periodic occurrences.

•          Continuous chronic episode.

b)           Progress (better, worse, unchanged),

c)           Effect of therapy.

 

 

                I.      Past History:

•        Neonatal history, including birth weight; approximate gestational age; maternal complications, such as extent of prenatal care, infections, exposure to drugs, alcohol or medications; and problems in the newborn period, such as prematurity, respiratory distress, jaundice and infections.

•        Immunizations

•        Development, noting the importance of assessing developmental milestones in evaluating the health of the child.

•        Diet, noting the importance of assessing the amount, type, and method of infant feeding.

             II.      Family History: number and ages of siblings; consanguinity, known genetic disorders, early childhood deaths, cardiovascular disease, depression and alcohol abuse.

          III.      Social History: assessment of the home environment, school and peer relationships.

          IV.      Review of Systems: the relevant items are limited, but expand as the patient’s age increases.

Modify the medical history depending on the age of the child, with particular attention given to the following age groups: neonate, infant, toddler/preschool aged child, school aged child, adolescence.

 

The Physical Examination

I. Establish rapport with children of various ages in order to perform the physical examination.

II. Recognize that the age of the child influences the areas included in the exam, as well as the order of the examination, and the approach to the patient.

III. Recognize the important role of observation as a method of obtaining data in the assessment of the child.

IV. Perform complete physical examinations on an infant, child and adolescent, including the observation and documentation of normal physical findings.

V. Demonstrate the appropriate use of the limited or focused examination, particularly in the ambulatory setting.

VI. Use developmental assessment as part of the physical examination for all ages.

•        Observe how normal behaviours, such as stranger anxiety, affect the ability of the examiner to perform the examination, and develop strategies for improving rapport.

•        Perform the Denver Developmental Screening Test, and know how it is used to assess motor, language and social development.

•        Identify the physical changes of puberty and be able to conduct Tanner staging.

VII. Observe and demonstrate physical exam findings unique to the pediatric age group, and understand how findings have different clinical significance depending on the age of the child. Some examples are:

•        Appearance

1.    Recognize signs of acute illness in an infant, toddler and child by evaluating skin colour, respiration, hydration, mental status, cry and social interaction.

2.    Recognize the importance of observing the psychosocial condition of the child, including behaviour, development, body habits (height, weight, body fat), relationship to parent and examiner, and general condition.

•        Vital signs

1.    Measure heart rate, respiratory rate, blood pressure and temperature in an infant and child, demonstrating knowledge of the appropriate sized blood pressure cuff, interval to count respirations, and normal variation in temperature depending on the route of measurement (oral, rectal, axillary or tympanic).

2.    Understand that normal values of the heart rate, the respiratory rate and the blood pressure change with age.

3.    Recognize the importance of assessing vital signs in the evaluation of acute illness.

•        Measurements

1.    Accurately measure height, weight and head circumference.

2.    Plot the data on an appropriate growth chart.

3.    Understand the normal relationships between height, weight and head circumference.

4.    Recognize the usefulness of longitudinal data.

•        Head

1.    Identify the anterior and posterior fontanels and assess them.

2.    Recognize the need for careful observation of the head size and shape, symmetry, facial features, ear size and hair whorls as a part of the examination for dysmorphic features.

3.    Recognize the red reflex and strabismus.

4.    Assess hydration of the mucous membranes. 

5.    Examine the tympanic membranes using pneumatic otoscopy.

•        Neck

1.    Palpate the lymph nodes, know what anatomic areas they drain;

2.    Know that the lymph nodes are more prominent during childhood

3.    Recognize and demonstrate maneuvers that test for nuchal rigidity.

•        Chest

1.     Remember how the rate and pattern of respirations change with age, and that abdominal respirations are normal in infants.

2.    Observe the rate and effort of breathing as a measure of respiratory distress.

3.    Recognize stridor, wheezing and rales and be able to distinguish between the inspiratory and expiratory obstruction.

4.    Interpret less serious respiratory sounds such as transmitted upper airway sounds.

•        Cardiovascular

1.    Palpate pulses in the upper and lower extremities and auscultate the heart for rhythm, rate, quality of the heart sounds and murmurs.

•        Abdomen

1.    Understand that the liver edge, spleen tip and kidneys may be palpable in the normal newborn.

2.    Examine the umbilical cord for signs of infection.

3.    Examine the abdomen for distention, tenderness, rebound and mass lesions in an infant or young child with lethargy, irritability or signs of acute illness, noting the inability of the patient to communicate symptoms of abdominal complaints.

4.    Be able to do a rectal examination and recognize when it is indicated.

•        Genitalia

1.    Recognize the appearance of normal male and female genitalia in the newborn.

2.    Recognize abnormalities, including cryptorchidism, hypospadias, testicular mass in the male.

3.    Be able to examine the external genitalia of a female patient.

4.    Recognize the need for privacy at all ages.

•        Extremities

1.    Examine the hips of a newborn for dysplasia.

2.    Recognize arthritis. 

3.    Evaluate gait and limp.

•        Back

1.    Know how to test for scoliosis.

•        Neurologic examination

1.    Elicit primitive reflexes.

2.    Assess tone, gait, strength and reflexes, recognizing the importance of symmetry.

3.    Assess developmental milestones; recognize that much of the neurologic examination of infants and children is accomplished through observation alone.

•        Skin

1.    Recognize jaundice, petechiae, purpura, common birth marks (such as nevus flammeus and Mongolian spots), vesicles, urticaria and common rashes, such as erythema toxicum, impetigo, eczema, diaper dermatitis and viral exanthems.

2.    Recognize common skin findings associated with child abuse.

3.    Assess skin turgor.

 

Inspection

The method of observation is used during physical examinations. Inspection, or “looking at the patient,” is the first step in examining a patient or a body part.

 

Palpation

The method of “feeling” with the hands is used during physical examinations. The examiner touches and feels the patient’s body part with his hands to examine the size, consistency, texture, location, and tenderness of an organ or body part.

Auscultation

This method used to “listen” to the sounds of the body during a physical examination can be performed by listening with the ear but is usually done by listening through a stethoscope. Health care providers routinely auscultate a patient’s lungs, heart, and intestines to evaluate the frequency, intensity, duration, number, and quality of sounds. Health care providers also use auscultation to listen to the heart sounds of unborn infants.

Percussion

A method of “tapping” of the body parts during Ошибка! Недопустимый объект гиперссылки.with fingers, hands, or small instruments to evaluate the size, consistency, borders and presence or absence of fluid in body organs. Percussion of a body part produces a sound (like playing a drum) that indicates the type of tissue within the organ. Lungs “sound” hollow on percussion because they are filled with air. Bones and joints “sound” solid. The abdomen “sounds” like a hollow organ filled with air, fluid, or solids.

 

I. Y. GORBACHEVSKY TERNOPIL STATE MEDICAL UNIVERSITY

DEPARTMENT of PEDIATRICS №2

 

 

The head of the department

Doctor of Medicine,

Professor G.A.Pavlyshyn

Manager of the group

____________________

 

 

MEDICAL CARD

__________________________________________________________________

name, surname of the patient

 

_______________ age of the patient

 

Clinical diagnosis: basic diagnosis ______________________________________

 __________________________________________

__________________________________________

Complication __________________________________________

__________________________________________

Concomitant disease __________________________________________

__________________________________________

__________________________________________

 

 

Mark for the writing

of the case history ______________  Curator ____________________________

The group __________, the course ______

Mark for the defense

of the case history ______________ 

 

 

TERNOPIL

2012

 

GENERAL INFORMATION ABOUT PATIENT

Name ________________________________

Surname _______________________________________________________________

Date of birth ____________________________, age ___________________________

Home address __________________________________________________________

Preschool or school institution _____________________________________________

Date of admission to the hospital ___________________________________________

Institution which has directed patient to the hospital ____________________________

Pre-admission diagnosis ___________________________________________________________________

___________________________________________________________________

Patient’s department _____________________________________________________

I.                   COMPLAINTS

Main: ________________________________________________________________

____________________________________________________________________

____________________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Additional: ____________________________________________________________

_________________________________________________________________________________

_____________________________________________________________________

 

II.                ANAMNESIS OF THE DISEASE

The onset of disease acute, subacute, gradually (the necessary underline). The duration of the diseases is ______________. What preceded the disease (cooling, defects of nutrition, viruses infection, the contact with ill person, etc) _____________________

_________________________________________________________________________________

_____________________________________________________________________

The development of disease _______________________________________________

____________________________________________________________________

_____________________________________________________________________

The result of previous additional methods of investigation (if they were presence) ____________________________________________________________________

____________________________________________________________________

_____________________________________________________________________

The previous treatment (if it was presence): ____________________________________________________________________

_________________________________________________________________________________________________________________________________________

The effect of previous treatment _____________________________________________________________________

_____________________________________________________________________

The reason of hospitalization _____________________________________________________________________

_____________________________________________________________________

III.             ANAMNESIS VITAE

For children till 3 years

The child from ____ (behind the account) pregnancy, _____ delivery. Age of the mother during the given pregnancy. The pregnancy proceeded (with, without) gestosis in ___ trimester, on a background (without) of the extragenital pathology _____________________________________________________________________

________________________, or inflectional diseases _________________________

 ___________________________________ or somatic illness ___________________

________________________________________________ in _______ trimester.

The mother used such medicines (to specify the trimester) ________________________________________________________________________________

_____________________________________________________________________

Harmful habits at the mother: ____________________________________________,

 at the father __________________________________________________________.

Conditions of work of the mother during pregnancy ____________________________

Conditions of life of the mother during pregnancy ______________________________

Delivery at timed or premature (the necessary underline), in ___ weeks of gestation. Labor via vaginal way or by cesarean section, with (without) medicamental stimulation _______________________ (the necessary underline). The child was mature or immature, according Apgar’s score _____ points at first min. and ____ points at 5th min. Birth weight was ______ g, length of the body was ___ сm, head circumference was ___ сm, chest circumference was ___ cm. The umbilical stump (residual cord) has fallen off in ___ days. After the stump has fallen off, the state of cord base was dry, or was weeping during __________ weeks.

The child discharged from maternity department on ____ day (when it was more than 5-6 days, specify the cause of delay) __________________________________________.

During the firs year the child was at ___________________ feeding. The reason of artificial feeding was ____________________________________________________. Mother used to such ______________________________________________________

formulas. The term of introduction of fruit juice __________, fruit puree ______, egg yolk __________, cottage cheese ___________, meat ____________. The first addition food was __________________ at _______ mo. The second addition food was _______ ____________ at _____ mo. The third addition food was _____________ at _____ mo.

The dynamics of body weight ______________________________________________ _____________________________________________________________________. Dynamics of body length _________________________________________________

_____________________________________________________________________. Dynamics of head circumference __________________________________________. Dynamics of chest circumference ___________________________________________. The psychomotor development of the child ___________________________________

__________________________________________________________________________________________________________________________________________ 

For all children irrespective of age

The child had such diseases (before admission) ________________________________

_____________________________________________________________________

_____________________________________________________________________

Housing conditions of the child is satisfactory or not satisfactory (the necessary underline and explain why) __________________________________________________________.

Character of nutrition before present disease (character of meal, schedule of feeding) __________________________________________________________________________________________________________________________________________.

Allergological history

Presence of allergy symptoms _____________________________________________. The intolerance of products _____________________________________________, that accompanied with ___________________________________________________, The intolerance of medicament (drug) _______________________________________

that accompanied with ___________________________________________________.

Prophylactic vaccinations _________________________________________________.

_____________________________________________________________________

The nearest relatives have such chronic somatic illnesses ________________________

__________________________________________________________________________________________________________________________________________, genetical illnesses ______________________________________________________,

allergic reactions _______________________________________________________.

Epidemiological history

The child didn’t contact with patients who suffered with inflectional diseases last 3 weeks. The symptoms of diarrhea were _______________ during last three days.

 

Objective examination of the child

The patient’s general condition is extremely grave, grave, moderately grave, satisfactory, good (the necessary underline).

The state of consciousness is clear, sopor, stupor, coma (the necessary underline).

The mental state is (not) adequate or not adequate (the necessary underline).

Position of the child in bed is active, passive, forced (attitude) (the necessary underline).

The patient is asthenic, hyposthenic, hypersthenic constitution (the necessary underline). The child is of regular, irregular body build (the necessary underline) _________________

_____________________________________________________________________

 

Anthropometrical measurements

Criterion      In patient     Norm

according empiri-cal formulas   Deviation, cm        Deviation, %

Weight, kg                                 

Height (stature), cm                                       

Head

circumference, cm                               

Chest circumference, cm                               

The index of fatness by Chulitska                                     

–

The index by Erismann                                –

 

Evaluating of physical development according percentile tabl             s

Criterion      percentile     Conclusion

Weight, kg             

Height (stature), cm                   

Head circumference, cm            

Chest circumference, cm           

 

Summary: _____________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

The Skin and mucous membranes

Colour of a skin ________________________________________________________

_____________________________________________________________________, 

lip-nose triangle ___________________________________, cyanoses _____________

_____________________________________________________________________.

Rashes (colour, characteristic lesions, localization, size, presence of warmth, itching, type of distribution) _____________________________________________________________

_____________________________________________________________________

Surface of a skin is (smooth, velvety, rough, dry, moist)__________________________________. The elasticity of the skin is ________________________________________________.

Temperature of a skin ___________________________________________________.

The dermographism is ___________________________________________________

Sensitivity of the skin: temperature ___________, pain ______________, tactile _____. Nails: (shape, colour, thickness, quality) _____________________________________, _____________________________________________________________________.

Hair: (color texture, quality, distribution, and elasticity) _________________________

_____________________________________________________________________

_____________________________________________________________________

Mucous membranes of a mouth (colour, moisture, presents of lesions) ______________

_____________________________________________________________________

Gums: (colour, presents of lesions, ability to bleeding) __________________________

___________________________. Conjunctiva and sclera of eyes _________________

_____________________________________________________________________. The subcutaneous fat is distributed _________________________________________. The skinfold thickness is _____ cm on abdomen, _____ cm under the scapula, _____ cm on the shoulder, _____ cm on thigh.  The oedema ___________________________

_____________________________________________________________________.  The skin turgor is kept, decreased, flabby (the necessary underline).

Lymphatic system

Such groups of lymph nodes are palpable (describe each group according their localization, quantity, size, shape, mobility, consistency (elastic or dense), temperature, tenderness and visible change of enlarged nodes) __________________________________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

The tonsils. The stage of enlargement of the tonsils ____________________________ they are reddened, loose, and tender on palpation (the necessary underline). Presence of haemorrhages _______ , pus in the crypts _________, erosions ___________________ ulcers __________________, the tonsils are covered with a ___________ (colour) film in size ____ cm. 

 

Muscular system

The development of muscles is satisfactory, well-developed; symmetric, asymmetric (the necessary underline), presence of atrophy on _______________________________. Muscular tone is _______________, hypotonia of _____________________________,  atony of ______________________________________________________________,  hypertonia _____________________________________________________________,  presence of muscular dystonia _____________________________________________. The range of motions is ___________________________________________________

_____________________________________________________________________ The strength of muscles ____________________________________________. Presence of pain during palpation of the muscles ______________________________. Presence of infiltrations or consolidation of ___________________________________ groups muscles. Trousseau’s sign is _____________, Chvostek’s symptom _________, Lust’s symptom _____________.

 

Bone system

Head circumference is _______ сm, (normal, microcephalia, macrocepalia (the necessary underline)). The head is dolichocephalic, brachycephalic, mesocephalic (the necessary underline). form (shape). There is hyperplasia of ________________________________ skull’s bones, occipital bones is _____ flat. Anterior fontanel (presence, size, shape, mould of the skull bones and attitude against the skull bony edges (does it taut or depressed) and pulsation) _________________________________________________

_____________________________________________________________________

Posterior fontanel (fused, size, shape) _______________________________________.

Lateral fontanels ______________________. Sutures __________________________.

The tooth formula:

                    p- permanent         * – caries

                    d – deciduous        O – growth disorder

Chest is conical, cylindrical, asthenic, normosthenic, hypersthnic, symmetrical, asymmetrical, barrel, funnel, keeled, phthinoid, rachitic breast (the necessary underline). Beading of the ribs _________. An epigastric angle ______ degrees. Chest circumference is _______ cm (normal, abnormal).

Spine (physiological curvatures, scoliosis and kyphosis) _________________________

_____________________________________________________________________

_____________________________________________________________________

The extremities are ___ symmetrical, ____ deformed with deformation _____________

_____________________________________________________________________,

anomalies of development ________________________________________________,

_____________________________________________________________________

The feet are ____ normal with deformations __________________________________

_____________________________________________________________________

Others bone are ________________________________________________________

_____________________________________________________________________

The joints (shape, size, temperature, the range of motion, tenderness, swelling, the change of the skin over them) ______________________________________________

_______________________________________________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________

Gluteal folds are ___symmetrical, _____________________________________ Angle of hip abduction is _____ degrees.

 

Cardiovascular system

 

Inspection: During inspection of the chest bulging ________ noted on left side, visible pulsation ______ seen, in _______ intercostals space ____________ line, epigastric pulsation _____ visible. Distended and pulsated neck veins ______ visible during inspection of the neck. Cyanosis ____________________________________________

_____________________________________________________________________, edema _______________________________________________________________, _____________________________________________________________________ 

Palpation: The apical or cardiac trust (beat) (the necessary underline). is located in ______ intercostals space ______________ line, area _____ сm2, is positive or negative (the necessary underline). Systolic or diastolic vibratory thrills (the necessary underline) _________ palpable at __________________. Pericardial friction rubs _________________________.

Pulse (rate) is _________ beats per minute; is rhythmic, arrhythmic; is synchronic asynchronic; is full, swift, galloping, large, small, soft, tense, thready; pulse deficit  (the necessary underline).

Blood pressure of upper extremities _____ mm Hg, of lower extremities _____ mm Hg.

Border’s of hearts relative dullness

Border         In patient     Norma

Right

                     

Upper           

Left

                     

transversal size                

 

Border’s of hearts absolute dullness

Border         In patient     Norma

Right

                     

Upper           

Left

                     

transversal size                

 

Auscultation: the heart sounds strong, weakened, muffled, rhythmical, arrhythmic (the necessary underline), ________ beats per min. S1 is heard loudest at the _______ of the heart, S2 is heard loudest at the _______ of the heart. Presence of accent ____________

_____________________________. Presence of organic, functional, systolic, diastolic, holosystolic, (the necessary underline) murmurs, place of the best auscultation __________

_____________________________________________________________________

_____________________________________________________________________

duration ________________________________, intensity ________________, timbre __________________, conductance _________________________________________ evaluation of its intensity in relationship to the child’s position ___________________ _____________________________________________________________________.

Extracardiac murmurs ___________________ (pericardial friction rubs, pleurocardiac),   localization ____________________________. During auscultations of carotic, subclavicular, femoral arteries, abdominal aorta, jugular veins are heard  ______sounds,  ___________________ murmurs.

 

Respiratory system

Cyanosis of nasolabial triangle, perioral region, nails plates, acrocyanosis __________ in rest or during physical exercises (the necessary underline). Nasal breathing is fee, difficult, absent (the necessary underline). Voice is normal, hoarse, soundless, snuffling, silent, aphonic (the necessary underline). Cough __________ present, dry, moist, troublesome, brassy paroxismal cough,  pertussis-like, barking cough,  constant, cough of mucus, cough of pus, blood spitting (the necessary underline), frequent in _________ time of day. Dyspnea, asphyxia ____________________ occurs in rest, during physical exercises (the necessary underline). Chest has cylindrical, conical, asthenic, normosthenic, hypersthnic, symmetrical, asymmetrical ______________________________, barrel, funnel, keeled, phthinoid, rachitic breast. The intercostal spaces are _______________,

Harrison’s groove ______________. Movements of etch parts of the chest are symmetrical, asymmetrical (the necessary underline) _____________________________________________________________________

Marked retraction of intercostal, suprasternal supraclavicular (the necessary underline) muscles ___________ noted.  Type of breathing is thoracic, abdominal, combined (the necessary underline). Dyspnea is absent, inspiratory, expiratory, mixed (the necessary underline). The respiration rate is _____ per minute (normal, tachypnea, bradypnea). The breathing is regular, irregular, deep, hard (difficult), paradoxical, periodic, shallow, interrupted, whistling, stridulous, stenotic, Kussmaul’s breathing, Cheyne-Stokes respirations, Biot’s breathing (the necessary underline).

Palpation: Pain is __________ in maxillary and frontal sinuses. Pain in chest ________ during palpations. Vocal fremitus is normal, decreased, increased, absent ___________

_____________________________________________________________________

Pleural friction rubs, crepitation ____________________________________________.

In comparative percussing of the chest is heard ________________________________

_____________________________________________________________________

 

 

The lower costal margin of the lungs according to topographic percussing

Line   right   left

midclavicular                   

midaxillary            

vertebral                

 

The excursion of the low margin of the lung (at midaxillary line) is ___ cm on left, ___ cm on right. The location of the apex of the lung _______________________________

_____________________________________________________________________

The width of Crenig’s areas _______________________________________________

Auscultation of the lungs: the breathing is ___________________________________

_____________________________________________________________________

presence of rales, rhonchi and crepitations ____________________________________

_____________________________________________________________________

Bronchophony is ______________________________________________________.

 

Digestive system

Inspection: The colour of mucous membranes of oral cavity is ____________, dry or moist (the necessary underline), incrustation (coating) _____________, fissure and aphtha _____________________________, colour of the tongue is _______________, coated with _______________ fur, state of papillas of tongue _______________________, dry, moist, atrophic, smooth, enlarged, normal size (the necessary underline). Colour of tonsils is ____________, coating ______________________, moisture _________ fissure and aphtha ______________. The odour from oral cavity __________________

In vertical position the abdomen has normal shape, distended, scaphoid, pendulous symmetrical or asymmetrical (the necessary underline) enlarged because of _________________________, abdominal circumference _____ cm, moves or doesn’t move with breathing, visible peristalsis ___________________, the umbilicus is centrally located, is flatten, inverted, everted, displased upwards (the necessary underline). In horizontal position the abdomen has ___________ shape, moves or doesn’t move with breathing, abdominal circumference _____ cm, the umbilicus is centrally located, is flatten, inverted, everted, displased upwards (the necessary underline). Distended veins of the anterior abdominal wall ______________, “caput Medusae” _________________.

In superficial palpation there is soft, mild, moderate, demonstrable, board-like muscular tension of anterior abdominal wall (the necessary underline). Hyperesthesias ___________, the divergence of straight muscles _____ present, the tumour _______ present in region _____________________________. Blumberg’ sign is positive or negative; painless, extreme tendernees in McBurney’s point (the necessary underline).

Deep palpation according to Obraztsov-Strazhesko

Sigmoid colon is localized in ________________________, _______________ shape, ________ size (cm), _______________ consistence, ___________________ character of surface, _________ painfulness, _____ movable, _________ murmurs.

Caecum is localized in ________________________, _______________ shape, ________ size (cm), _______________ consistence, ___________________ character of surface, _________ painfulness, _____ movable, _________ murmurs.

Colon transversum is localized in ________________________, _______________ shape, ________ size (cm), _______________ consistence, ___________________ character of surface, _________ painfulness, _____ movable, _________ murmurs.

Colon ascendens: is localized in ________________________, _______________ shape, ________ size (cm), _______________ consistence, ___________________ character of surface, _________ painfulness, _____ movable, _________ murmurs.

Colon descendens is localized in ________________________, _______________ shape, ________ size (cm), _______________ consistence, ___________________ character of surface, _________ painfulness, _____ movable, _________ murmurs.

Mendel’s symptom is positive or negative (the necessary underline). 

The liver ______ palpable, ______ tender, is extended ____ cm below the costal margin, shape of edge is sharp, rounded, smooth, elastic, firm (the necessary underline). Ortner’s symptom is _________, Ker’s symptom is _________, Murphy’s symptom is _________, Mussi-Georgievsky’s symptom is _________. The spleen ______ palpable, ______ tender, is extended ____ cm below the costal margin, shape of edge is sharp, rounded, smooth, elastic, firm (the necessary underline).

Meyo-Robson’s symptom is _________. The pancreas _____ palpable, ____________

consistency, ______ tender, smooth, elastic, firm (the necessary underline).

In auscultation intestinal peristalsis is absent, sluggish, increased, not impaired, (the necessary underline).

Stool is _____ time per day, formed, liquid, semi-liquid, regular, irregular (the necessary underline), _________ colour, with or without an admixing _______________________.

 

Urinary system

Inspection:  _________ oedema on legs ___________, face, sacral part, on the lower part of abdomen. The colour of lumbar region is ________. The odour of urine is _____

Examination of sacral area, lower abdominal part (changing of the color of the skin ___________________, protrude ______________________, edema______________, asymmetry_______________________).

Examination of the external sex organs: stage of development ____________________. Presence of excretion from urinal channel _____________________.

In boys: asymmetric, symmetric development of the scrotum (the necessary underline). Tests _________ present in the scrotum; presence of inflammation of penis, _________ anomalies of penis development, phimosis, paraphimosis (the necessary underline).

In girls: colour of mucous membranes of external sex organs is __________________,  presence an excretions from vagina _________________________________________.

Kidneys ______ palpable in vertical or horizontal position, _______________shape, _________________ consistency, _______ movable, ______ tender, smooth, firm (the necessary underline). Pasternatsky’s symptom is _____ on right , ________ on left side.

Urinary frequency _____ per day, Daily urine flow _________ ml, proportion between day and night diuresis ____________. Presence of uncontrolled urinations _________.

Endocrine system

Examination: face expression __________________, presence of the eyes symptoms ____________________________________________________________________, changes of anterior cervical surface __________________. The level of development subcutaneous fat is ____________________________________________________. Thyroid gland _____ palpable, of _______ stage, ___________surface, ___________ consistence, ____________ pain.

Sex development (according formulas F, L, Ax, P, V for boys and for girls – Ma, Ax, P, Me) __________________________________________________________________

Summary ______________________________________________________________

_____________________________________________________________________

Nervous system

The consciousness is kept, stupor, sopor, is absent (the necessary underline). The mental development ______ corresponds to the age of child. Reaction on environmental is does not adequate (the necessary underline). Dream is isn’t quiet (the necessary underline).

Expression of the face is ___________________. There are some minor abnormalities

_____________________________________________________________________

_____________________________________________________________________. Nystagmus is ___________ horizontal, vertical. Pupils are (un)equal in size; presence of mydriasis, miosis (the necessary underline). The light reflex is retained (absent). The coordination of movement _______ kept.

The pain sensitivity is kept, (is absent, hyperesthesia, hypoesthesia) (the necessary underline). Tactile sensitivity is kept (is absent, pathologic) (the necessary underline). Thermoesthesia is kept (is absent, pathologic) (the necessary underline). Vibration sensation is kept (is absent, pathologic) (the necessary underline).

Newborn reflexes (the necessary underline): Sucking – is normal, hypoactive, hyperactive;  Rooting  – is normal, hypoactive, hyperactive; Defence – is normal, hypoactive, hyperactive; Lip or trunk reflex – is normal, hypoactive, hyperactive; Grasp – is normal, hypoactive, hyperactive; Babinski’s – is normal, hypoactive, hyperactive; Moro – is normal, hypoactive, hyperactive; Supporting – is normal, hypoactive, hyperactive; Dance or step – is normal, hypoactive, hyperactive;  Perez – is normal, hypoactive, hyperactive; Crawling – is normal, hypoactive, hyperactive;  Bauer’s – is normal, hypoactive, hyperactive; Galant – is normal, hypoactive, hyperactive. Upper Brudzinski’s reflex – is normal, hypoactive, hyperactive; middle Brudzinski’s reflex – is normal, hypoactive, hyperactive; low Brudzinski’s reflex – is normal, hypoactive, hyperactive. Tendon reflexes brisk, (equally marked on both sides, more hyperactive on the ______ than on ______ side, equally diminished, increased) (the necessary underline). Karniga’s sing positive, negative (the necessary underline). The paralyses (palsy) _____________________________________________________________________

The hyperkinesias _____________________________________________________

The dermographism is red, white, stria with ____ см in wide, appears in ____ second, disappears in ____ second, arises over surface of a skin (the necessary underline).

The pilomotor reflex – pulse is increasing (is decreaseing) for ____ minutes (the necessary underline). Reflex by Danini-Ashner – pulse is increasing (is decreaseing) for ____ minutes (the necessary underline). The orthostatic reflex – – pulse is increasing (is decreaseing) for ____ minutes (the necessary underline), blood pressure decreased for systolic _____ mm Hg, diastolic _______ mm Hg.

 

Psycho-motor development of the child

Gross motor development _________________________________________________

__________________________________________________________________________________________________________________________________________

Fine motor development __________________________________________________

_____________________________________________________________________

Sensory development _____________________________________________________

_____________________________________________________________________

Vocalization development _________________________________________________

_____________________________________________________________________

Socialization development _________________________________________________

_____________________________________________________________________

Summery: ______________________________________________________________

 

 

 

Substantiation of the provisional diagnosis

On the establishment of the patient’s complaints _______________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Anamnesis morbi _______________________________________________

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Anamnesis vitae  _______________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Genetic anamnesis ___________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Data of objective examinations ___________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

It possible to make provisional diagnosis : ____________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ The plan of examination of the patient

1)                  ___________________________________________________________________

2)    ___________________________________________________________________

3)    ___________________________________________________________________

4)    ___________________________________________________________________

5)    ___________________________________________________________________

6)    ___________________________________________________________________

7)    ___________________________________________________________________

8)    ___________________________________________________________________

9)    ___________________________________________________________________

10)             __________________________________________________________________

11)             __________________________________________________________________

12)             __________________________________________________________________

 

 

Results of additional methods of examination

Rooting blood analysis

date    Нb     Eryth.

х1012 CI      Leuc

х109   eos     bas     juv.    band  seg.    lym    mon   ESR   Blood clotting time

          Bleeding time

                                                                                                                                              

                                                                                                                                              

 

The general examination of urine

date    Amount       Spesific gravity      pH     Proteinuria   Glucosuria   ketonuria          Epithelium

 

 

          Leucocytes   Erythrocytes

          Casts

          Cristals:

          Mucous

                                                                                                                         

 

 

                                                                                                                         

 

Urinal examination according to Nechepurenco _______________________________

 

Biochemical analysis of blood

date    protein         glucose        bilirubin      creatinine     urea   ALT   AST          Amylase

          total            total   conjugated                                           

                                                                                           

                                                                                           

 

Urinal examination according to Zymnitzky

Portion        1        2        3        4        5        6        7        8

Quantities

of urine                                                                             

specific gravity                                                                            

 

Stool test ______________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Analysis of feces on worm ova _____________________________________________

_____________________________________________________________________

Test on enterobiosis ______________________________________________________

_____________________________________________________________________

Others methods  of examination __________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ECG: _________________________________________________________________ __________________________________________________________________________________________________________________________________________

USD __________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Endoscopies examination of  ______________________________________________

_______________________________________________________________________________________________________________________________________________________________________________________________________________ 

X-ray examination ______________________________________________________

_______________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Differential the diagnosis

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Clinical diagnosis

On the establishment of the patient’s complaints _____________________________

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Anamnesis morbi ______________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Anamnesis vitae  __________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Genetic anamnesis ______________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Data of objective examinations ____________________________________________

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Data of additional methods of examination ___________________________________

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

It possible to make clinical diagnosis:

basic diagnosis __________________________________________

 __________________________________________

__________________________________________

Complication __________________________________________

__________________________________________

Concomitant disease __________________________________________

__________________________________________

__________________________________________

The temperature list

data

BP

P

T

M

E

M

E

M

E

M

E

M

E

M

E

M

E

M

E

M

E

M

E

M

E

M

E

M

E

M

E

Stool

Weight

diuresis

           

Treatment of the patient

Regimen ____________________________________________________________ ______________________________________________________________________

Diet № ___ _______________________________________________________ ____________________________________________________________________________________________________________________________________________ 

The menu for infant:

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Medicamental treatment:

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Physiotherapeutic measures:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Epicrisis

The patient ____________________________________________________________

_______ age, __________ date of birth, home address __________________________

_____________________________________________________________________ _____________________________________________________________________ received treatment in __________________________________________________ _______________________ from ________ 200_ on _______ 200_  with the diagnosis of: ___________________________________________________________

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

The general state and data of objective examination of the patient on admission (shortly) ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 

Rooting blood analysis

date

Нb

Eryth. х1012

CI

Leuc х109

eos

bas

juv.

band

seg.

lym

mon

ESR

Blood clotting time

Bleeding time

The general examination of urine

date

Amount

Spesific gravity

pH

Proteinuria

Glucosuria

ketonuria

Epithelium

Leucocytes

Erythrocytes

Casts

Cristals:

Mucous

Urinal examination according to Nechepurenco _______________________________

Biochemical analysis of blood

date	protein	glucose	bilirubin		creatinine	urea	ALT	AST	Amylase
	total		total	conjugated

Urinal examination according to Zymnitzky

Portion	1	2	3	4	5	6	7	8
Quantities of urine
specific gravity

 

Stool test ______________________________________________________________

_____________________________________________________________________

_____________________________________________________________________

Analysis of feces on worm ova ________________________________________

_____________________________________________________________________

Test on enterobiosis ________________________________________________

_____________________________________________________________________

Others methods  of examination __________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

ECG: _________________________________________________________________ __________________________________________________________________________________________________________________________________________

USD __________________________________________________________________ ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Endoscopies examination of  ______________________________________________

_______________________________________________________________________________________________________________________________________________________________________________________________________________

X-ray examination ______________________________________________________

_______________________________________________________________________________________________________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Prescribed treatment

_____________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Dynamic of the main syndromes during treatment; the objective state of the patient at the moment of his discharge from the hospital

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

Recommendations:

1. Diet № ___________________________________________________________

2. Regimen ___________________________________________________________ 

3. Medical measures _________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

4. Sanatorium treatment __________________________________________________

__________________________________________________________________________________________________________________________________________ 

Literature

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

 

The curator (signature) __________________

 

laboratory methods of functional state of organs and system. Rulers and technique of taking materials for examination. Methods of examination of Immunodeficiency states in children

 

 

         Laboratory  methods  of  investigation  of  functional  state  of  organizm   and   systems  of    child  organizm.

Rules  and  technics  of  stuff  collection  for  the  research.

 

 

 

Grafical structure of theam.

Chemical-           Methods of hematologikal investigation:

Concentration HB in 1 mcl of blood.

Number of eritrocytes in 2 mcl of blood.

Colour indicator

Number of leucocytes in 1 mcl of blood.

Formula of leucocytes.

Speed of sedamentation of eritrocytes.(mm/hour)

reticulocytes, resistans of eritrocytes E cells, basis phosphatosa, glicogen, fats, trombocytes.

Methods of investigation of homeostasis system:

methods of investigation: trombocyto-vessels homeostasis: time of bleeding , resistanse  of capilars, number of trombocytes, retention of trombocytes, aggregation of trombocytes, retraction of blood clot.

intestigated methods of blood: rolling time of blood rolling ;

 

General rules of taking blood samples for tests are the following:

–        It is advisable to do it in the morning, on empty stomach

–        Before taking medical products

–        Physiotherapeutic procedures are forbidden before the tesr

–        It is advisable to avoid physical and psychological stress before taking blood samples for test

–        Blood is usually taken from the tip of the third phalanx of finger, in children of early age, it is possible to take blood from the soft part of heels, in some cases it I possible to take blood from vein

 

Erythrocytes and hemoglobin

The normal quantity of erythrocytes in children differs according to age

Quantity of hemoglobin (Hb)

 

 

Neonatal period    

 

 

Urine        physical properties:

microscopial                         clearness, pH, spesific gravity

methods                                chemical properties:

protein, glucosa, suggar,

                                              ketone bodies, biliary  pigments

microscopi of sediment:

leukocytes, eritrocytes, cylindres, endotelial cells.

                             Stool        phisical properties:

stell, shope, pH, visible admixture, colour.

chemical properties:

blood, stercobilin, bilirubin, aminoacid, amonium.

microscopia :

dedritis, muscular fibres, connective tissue, cellulose and amylum, fat acid, soap, mucousis, cells of intestinal epitelium, leukocytes, erytrocytes, hamblia, helminths

 

 

Sputum    phisical properties:

quaulity, colour, solidity, smell, divigion on the levels, character,

chemical properties: proteins, bilirubin.

microscopia: Krusherman’s spirals, eozinophiles, Sharko-Leyden’s cristals,elastic fibres, alveolar macrophages, Litrish’s corcs, echinococus elements.

bacterioscopia: microorganism of tuberculosis microflora.

 

Native preparates:

Ecsudat and transudat:

phisical and chemical properties specific gravity, presents and quolity of proteins.

microscopia: eritrocytes, leicocytes, tumor’s cells, dedrites, fat cells, cristale  of cholesterin, mucosis, actinomicetes.

paint preparates: neurophites leucocytes limlhocytes, losipophiles, plasmatic cells, histeocites, macrophages, cells of mesotelium, tumor’s cells.

 

bacterioscopia: microbacterium of tuberculosis.

 

Liquor        phisical properties: colour         specific gravitis

microscopia: limphocytos, plasmatic cells, monocytes, macrophages, neutrophiles, eosinophiles, epiteliae cells, cristals, tumor’s sells, echinococus elements.

clinikal investigation: protein, suggar, chlorides, globulines.

time of retraction stabilisated blood, protrombine time, tromboelastographia, electrocoalographia, researching of blood rolling factors, concentration of antiroling factors, fibrinogens, and its following substanses, activiti of VIII factor.

Methods of investigation of fibrinolitical system of blood

general methods: measuring of time of lisis blood clots or euglobuline fraction of blood.

 

Methods of clinical biochemistri

Investigation of conteins general proteins, protein fractions, sedimentation test,(timoles, sulemo’s, deltman’s test),enzimes,(AlAT, AcAT,LDG,amylasa, lipasa etc) low-molecular nitrates substanses (blood urea, creatinina,urea ecid, aminoacides and peptides, indicane, pigments (bilirubin, porphirines); hydrocarbonatis ( glucose, lactat, acid, suggar,); fats (cholesterin,and its etheres threeglycerides, phosphlipides).

 

 

Urine: for investigation tace all portion of morning  urine after diligent toilet of sexual organs; in the clean and dry plates; keep only 1,5 hour not more in could place.

150-200 ml – for investigated of phisical properties.

Demands to the researches material

Stool: investigated not more 8-12 hours after its secretion; keeping in temperature 3-5 C ; collected in dry and clean plates (wishes glasses)

Gastrik     physical properties:                         

secretion  quantity, colour, smell,   admixture.

                 chemical properties:              

 total acidy, free acidy, debit HCL, presents of milk acid (lactat)

 

Gastric juse: receiving of emply stomach, after stimulation, aspiration basiae and stimulated juse.

Sputum: fresh secretion spidun in cough collected in the dry, clean plates (wishes glasses), before secretion child rinse oral cavity by boling water; in babies we can call cough by means to tough with stranges on the radix of toung, collection by means special instrument in the Petri’s cap. For desinfection –5% solution chloramine.

Transudat and ecsudat: receiving in punction of cavities, collected in clean dry plates, add citrat of sodium (1g on 1l) , or heparin, and all this mixture send immideatly on the investigation.

Lijuor: receive it by neans lumbal , suboccipital and ventricularpunction, which leaded in operating or procedure room; collected in dry and clean bottle, for bacteriological investigation – on the sterilisate bottle.

 3.Technics of collection material for investigation

 Taking the throat and nasal kavity svab

 Make use of sterial cotton wool tampons on the small stisk it the steril test-tube; whith left hand press on root of tongue, and with right hand take off tampon from test-tube. Touch to surfacies of tonsile glands , and take off from mouth and put into tese-tube; with left hand a little raise the end of nose and with right hand tampon put into the first in the right then in the left nasal ways with turn moves. Then fasten to the test-bube card with surname of patient, aim of investigation, date of takinganalyses. Thenimediatly to send it in the laboratory.

Collection sputum for bacteriological investigation

 

In the steril cup of Petry

Common rules collection of urine:

           The first portion of urine have to be taking after    slipping in the morning;

Before taking the analysis the patient must be washed and he have to collect the urine in the clear bottle,then send it to laboratory.

 

General analyses of the urine:

Collect the morning urine, middle; inverstigate physical properties, and lead microscopy.

 

Bacteriological investigation:

10 ml of urine in the steril test-tube.

 

Quantities method:

Method of Kakovsky-Addis:

In the clear bottle collect urine, which was excreted of urine while 10 night’s hours(from 22 to 8) Count formed elements of daily urine

 

Ambyrze’s method

Use for investigate “minute leukocyturia” formed elements which excreted of urine while one minute

 

Nechepurenko’s method

Taking middle portion of urine,near 2-3 ml.

Count number formed elements in the 1 ml. Urinary sediment.

 

Zymnyckiy’s test

Collect 8-portion urine while 24 hours; from 6(this portion do not take).While every 3 hours to the 6 of other day.

Collect of faces

 

Koprologik investigation includes four groups of methods: bacteriologic,chemical,micro and macroscopic methods.

Faces should be taken from the middle. Every portion investigate  separately. Morning faces are sent to the laboratory in the dry, clear bottle.

 

Semiotics disorders

 Changes from the side of  general blood analysis:

 

 

Anemia, erythremia, increasing or decreasing of hemoglobin, color index,

Thrombocytopenia, raised leucocytes, bond neutrophils, eosinophils,lymphocytes, elevation of the erythrocytes sedimentation rate.

Changes from the side of  general analysis of urine:

Low or high specific gravity of urine, proteinuria, ketonuria, glucosyria, leucocyturia, casts in urine, bacteria’s in urine.

Changes from the side of  koprograms:

Indigested muscular fibers,steatorrhea, lientery, bacteria’s in the feces.

Changes from the biochemical analysis of the blood side:

Decrease blood protein, lipids, Ca, P, sugar.

Increase blood urea, creatinine, bilirubin.

Changes from liquor’s side:

Increase protein, sugar, leucocytes, presents meningococs, microbacterics tuberculosis.

Changes from sputum analysis side:

Increase proteins, presents: columnar ciliated epithelium, alveolar macrophages, siderophages, elastic fibrils, Charcot-Leiden crystals, Kurschman’s spirals, Ditrich’s plugs, microbacteries tuberculosys.

 

INSTRUMENTAL EXAMINATION OF CHILDREN WITH GASTROINTESTINAL PROBLEM

 

Rapid strides have been made in gastro-intestinal endoscopy (gastroscopy, colonoscopy, ERCP, and related techniques) in the last thirty years. Gastro-intestinal endoscopy, once largely diagnostic, has evolved such that therapeutic procedures are often performed at the same time. This may prevent the need for major surgery. Safe and effective sedation has been a major factor in the development of therapeutic endoscopy. However, not all patients require sedation for endoscopic procedures. Some patients are quite comfortable with no sedation, or only minimal sedation, depending on the type and duration of the procedure.

Patients usually have three major concerns prior to endoscopy – the outcome of the procedure (could it be cancer?), complications of the procedure, and most importantly the question “Doctor, how much will I feel the procedure?” or “Will it hurt?” With modern sedation and careful monitoring the great majority of patients will feel comfortable during the procedure.

Before the Endoscopy

It is most likely that you will have your endoscopy in a day surgery unit in a public or private hospital. During the procedure an anaesthetist or sedationist (doctor or nurse trained in sedation and resuscitation) will be present throughout the procedure to provide monitoring of your level of consciousness, your cardiorespiratory state and provide the right amount of anaesthetic sedation to keep you comfortable throughout.

Prior to the procedure, you will meet the doctor giving the sedation. You will be asked (by the doctor or nursing staff) to provide your medical history, including the reason you are having the test, whether you have heart or lung disease (including asthma, angina or heart failure), liver or kidney disease, gastro-intestinal bleeding or other bleeding problems, or anaemia. The anaesthetist will wish to ensure you have fasted (i.e. not had food or drink) for the required number of hours before the procedure. A brief physical examination may be performed. If you are dehydrated, intravenous fluids may be administered. The doctor will wish to know your allergies and a list of your medications.

This is the time to ask any questions you may have regarding the sedation. An intravenous cannula or needle will be placed in the back of the hand or forearm. This is for the administration of intravenous sedative drugs.

During the Endoscopy

When you are wheeled into the procedure room, you will be connected to monitoring equipment which is essential when sedative agents are to be used. Monitoring detects early signs of impaired lung or heart function resulting from the sedatives, permitting early correction, thus maximising patient safety. Years ago, the anaesthetist would monitor the patient by checking skin colour, pulse rate, and rate of breathing. Modern equipment, in combination with careful clinical observation, can do much better than this.

You will also be given a mask or some type of oxygen delivery system to increase the level of oxygen in the air that you are breathing – this is now standard for endoscopic procedures. Oxygen will continue throughout the procedure. When you are asleep you may be aware of suction in the mouth or throat, which is used to remove any unwanted secretions.

After the endoscopy

Usually you will be regaining conscious awareness just as you are being wheeled to the recovery area. You may be attached to the same monitors as were used in the procedure area. You will be closely monitored at this time by experienced nursing staff, who will check your blood pressure and vital signs frequently. This is a time to relax and gradually awaken. A long awaited cup of tea and a light meal may be provided about an hour after your procedure. Often it is wise to eat only lightly for the rest of the day following an endoscopic procedure.

You will be fit for discharge when you are wide awake, have had some food, and are able to get up, get dressed, and walk around without any unsteadiness. Another person should accompany you home. You must not drive or use machinery for the remainder of the day.

Remember:

For the remainder of that day (and sometimes the next, if you still feel tired and unsteady),

do not –

•        drive a motor vehicle

•        use machinery that requires judgement or skill

•        drink alcohol

•        cook (because of the risk of burns)

•        take sedative medication unless prescribed by your doctor

•        sign legal documents

•        make major financial decisions

•        be the only person in charge of children or other dependent individuals.

 

 

Pulse Oximetry

Pulse oximeters are the most important monitors to have been developed in the last fifteen years. They should be used in every endoscopy procedure room, and be available in recovery areas.

The pulse oximeter measures the differential absorption of red and infra-red light by oxygenated and deoxygenated haemoglobin. A light emitting diode, located in a fingertip probe, sends a light wave through the tissues and monitors the reflected wavelengths coming back as the blood passes through the capillaries. The pulse rate and oxygen level (saturation) of haemoglobin in the blood can be measured. All healthy patients will have an oxygen saturation greater than 96% when breathing room air. If the oxygen saturation in the blood drops, the machine will alarm, and the anaesthetist will undertake measures to correct the situation to avoid an emergency.

 

Blood Pressure and ECG Monitoring

These measures are also frequently used when sedative agents are given, particularly in elderly patients or patients who have a cardiac history. The ECG is useful for detecting cardiac rhythm abnormalities (arrhythmias) and insufficiency of blood supply to the heart muscle (cardiac ischaemia).

A typical print-out from a patient monitor is shown below. The top tracing is an ECG, the bottom tracing the pulse rate. The monitor also shows continuously the pulse rate, the last blood pressure recording, and the oxygen saturation.

 

 

Colonoscopy

 

What is the Purpose of Colonoscopy?

To examine the lower gastrointestinal tract (colon or large bowel), to remove polyps (small benign growths), inject bleeding blood vessels, and to take samples of tissue (biopsies) for examination by a pathologist. Colonoscopy is the most reliable method of bowel examination but small abnormalities including cancers can very occasionally be missed.

 

How are you Prepared?

Prior to the procedure you will be given a bowel preparation kit with instructions. The bowel preparation cleans the colon. Without this it is not possible to perform a full examination of the colon. Although the bowel preparation is unpleasant, it is very rare for it to be harmful. If you have had difficulties with the preparation in the past, or if you have severe heart, lung, or kidney disease you should discuss this with the doctor.

How is Colonoscopy Done?

A long, thin flexible tube is passed around the bowel from the anus. This takes about 15 minutes and is done under intravenous sedation (Midazolam, Fentanyl, and sometimes Propofol). Reactions to these medications are rare. After the procedure you must not drive or use machinery until the next day, or longer if you feel unsteady or tired the next day. If you object to the use of sedation please discuss.

Colonoscopies are done in a hospital, usually on a day case basis. You would be required to attend the hospital for about 3 hours if you have sedation for your colonoscopy. You will need to arrange transport to and from the hospital.

Are there Alternatives to Colonoscopy?

A barium enema x-ray of the bowel will give similar information but it is not as accurate for certain problems, it does not allow biopsies or removal of polyps. It does not require sedation or hospital admission.

Complications

Colonoscopy and polypectomy are very safe. Serious complications are rare. These include:

•        Reaction or sensitivity to medication used for sedation (this may affect your breathing briefly)

•        Perforation (puncture) of the lining of the bowel (about 1 patient in 2000-5000)

•        Bleeding – if blood vessels are injected or a polyp is removed (about 1 patient in 300-500)

•        Infection of the bowel, blood, and other organs

•        Heart attacks, cardiac arrest, blood clots, and breathing problems (very rare)

•        There are other very rare complications – please advise if you wish to be given more details

Everything will be done to minimise the risk of these complications. There are ways of detecting these complications early and specific treatments are available if they do arise. Very rarely there may be a need for hospitalisation, major surgery, intravenous feeding, or blood transfusion. Although death can result from complications of colonoscopy this is very rare.

 

Special Precautions will need to be taken:

•        if you suspect or know you are pregnant or if you are breastfeeding

•        have severe heart, lung, or kidney disease

•        have lymphoma, leukaemia, or you are receiving chemotherapy

•        if you have had heart valve disease, a pacemaker, aortic graft or other blood vessel graft

•        if you bleed very easily or if you take blood thinning tablets (warfarin), aspirin, or arthritis tablets

•        if you are allergic or sensitive to any medication

 

Liver Biopsy

A liver biopsy involves your doctor taking a small piece of tissue from your liver so that they can examine it to see if there is any damage or disease to the liver.

The reasons why your doctor may want to do a liver biopsy could be that your liver function tests (LFTs) may be abnormal, possibly suggesting that your liver is not working properly or you may have an enlarged liver. For the doctor to accurately determine what is wrong with your liver, a liver biopsy may be the best approach.

Before you have your liver biopsy, the doctor will do some tests to ensure that the risks of the biopsy are kept to a minimum. First, your doctor will take some blood to see if it clots properly (since the liver produces some of the factors that help blood to clot). Your doctor will also ask you what medications you take . make sure you mention .blood thinning. medications, including aspirin. One week before surgery, it is recommended that you stop taking aspirin, ibuprofen and anticoagulants (such as warfarin).

You have to go to the hospital for a liver biopsy. For the biopsy, you will be lying on a hospital bed and the nurse will put in an intravenous (IV) line so that you can be given medication for the procedure.

When you have the biopsy, you will be lying on your back or turned slightly on your left side, with your right arm above your head. You will be given some local anaesthetic with a needle to numb the area and then the doctor will make a small incision (.cut.) in your right side, near your ribcage. The doctor will then put a biopsy needle in and take out a small piece of your liver within the needle. Sometime the doctor may use an ultrasound image of your liver to help guide the needle to the right spot.

The doctor will ask you to hold your breath for 5-10 seconds while they put the needle into your liver. You might feel a dull pain when this happens. The actual procedure should take only a few minutes. After the biopsy, you will get a bandage put over the incision and you will have to lie on your right side, pressed up against a towel, for at least 2 hours. Sometime patients may need to stay in hospital for up to 24 hours after the biopsy to recover from the sedative and to allow the medical staff to check for complications before you can go home.

Since you may be having a sedative, you will need to arrange for someone to drive you home, as you can.t driver after having a sedative. You have to go directly home and remain in bed for 8-12 hours, depending on what your doctor tells you. And to make sure that the incision and you liver can heal, you shouldn.t exert yourself too much for the next week. You might get a little bit of soreness at the incision site and you might get some pain in your right shoulder.

There are some risks involved in having a liver biopsy, such as puncture of the lung or gallbladder, infection, bleeding and pain, but these complications are rare. You should ask the doctor about these complications, how to recognise them, and what action to take.

 

Endoscopic Retrograde Cholangio-Pancreatography (ERCP)

 

The nature of the test, including possible side-effects and complications, will be discussed with you before the test. If you wish to have more information please advise your doctor before the test.

What is the Purpose of ERCP?

To examine the bile ducts and pancreatic ducts, to remove gallstones from the bile ducts, to dilate strictures in the bile ducts, to dilate or cut strictures due to a tumour of the duodenum, pancreas or bile ducts, and to keep open a stricture by the use of a plastic or metal tube called a stent. The procedure also allows samples of tissue (biopsies) to be taken for examination by a pathologist.

Sphincterotomy

Sphincterntomy involves making a small cut in the lower part of the bile duct where the duct opens into the duodenum. This is done using an instrument passed through the endoscope. You do not feel the cut. This procedure allows better access into the bile duct, removal of gallstones, and other procedures to be performed.

 

How are you Prepared?

Prior to the procedure you will asked not to eat or drink, usually for 8 hours. This is to allow a satisfactory examination and to minimise the risk of vomiting during the test. You will be asked to come to the hospital before the test to complete admission procedures, be admitted and checked for any medical problems, have an intravenous line inserted, and have any premedication and antibiotics if required.

 

How is ERCP Done?

The test is done in the X-Ray Department (you will be taken there from the Ward). After the sedation is given, a long, thin flexible tube is passed into the stomach via the mouth and a thin plastic tube inserted into the bile and pancreatic ducts. In about 5% of patients this is not successful. The procedure takes up to 45 minutes and your are under intravenous sedation throughout (Midazolam, Fentanyl, and sometimes Propofol). Reactions to these medications are rare. After the procedure you must not drive or use machinery until the next day, or longer if you feel unsteady or tired the next day. If you object to the use of sedation please discuss with your doctor.

Are there Alternatives to ERCP?

Similar information can be obtained by Percutaneous Cholangiography which is done by a Radiologist. This is generally a more difficult procedure with a slightly higher risk of complications. Removal of gallstones and treatment of strictures and tumours also can be done by open surgery, which involves an operation under general anaesthetic, a much longer stay in hospital, and higher risk of complications. If gallstones are left in the bile ducts, or if blockage of the bile ducts is not relieved, life-threatening problems may occur.

Sometimes ultrasound, CT cholangiography, and MRI cholangiography can give very similar information to that provided by ERCP, however these investigations do not allow therapeutic procedures to be performed. Your doctor will discuss these investigations with you if you wish.

 

Complications

ERCP, sphincterotomy, and stent insertion are normally safe procedures and are only done when other methods of diagnosis or treatment have failed. Complications (mostly minor) occur in about 5% of patients, including:

•        Reaction or sensitivity to medication used for sedation (this may affect your breathing briefly)

•        Pancreatitis (inflammation of the pancreas) (mild pancreatitis occurs in about 1 patient in 20)

•        Bleeding following sphincterotomy (about 1 patient in 100)

•        Perforation (puncture) of the lining of the duodenum or bile duct (about 1 patient in 1000)

•        Infection of the bile ducts, blood, and other organs

•        Incomplete removal of gallstones due to impaction, or to an instrument impacting in the bile duct

•        Stent displacement with damage to bowel wall including perforation & bowel obstruction

•        Heart attacks, cardiac arrest, and breathing problems (very rare)

•        There are other very rare complications – please advise if you wish to be given more details

Everything will be done to minimise the risk of these complications. There are ways of detecting these complications early and specific treatments are available if they do arise. Very rarely there may be a need for hospitalisation, major surgery, intravenous feeding, or blood transfusion. Although death can result from complications of ERCP this is rare.

ERCP is a technically difficult procedure and in about 5% of patients there is a need to repeat the procedure at a later date for a variety of reasons e.g. to check that gallstone extraction has been successful, or to remove residual gallstones.

 

Special Precautions will need to be taken:

•        if you suspect or know you are pregnant (x-rays are used in this test) or if you are breastfeeding

•        have severe heart, lung, or kidney disease

•        have lymphoma, leukaemia, or you are receiving chemotherapy

•        if you have had heart valve disease, a pacemaker, aortic graft or other blood vessel graft

•        if you bleed very easily or if you take blood thinning tablets (warfarin), aspirin, or arthritis tablets

•        if you are allergic or sensitive to any medication, including iodine

Some useful links providing further information:

ASGE policy and procedure manual on GI endoscopy

http://www.asge.org/gui/patient/index.asp

General information about colonoscopy

http://www.gastro.com/html/colonoscopy.shtml .

 

Immunologic deficiency disorders

To understand immunologic deficiency disorders and their serious, often life-threatening consequences, it is helpful to review the normal functioning of the immune system. In simple terms the function of the immune system is to recognize “self” from “non-self” and to initiate responses to eliminate the non-self or the foreign substance known as antigen. However, the specific processes involved in this function are complex and interrelated. The following is a review of the major responses.

The immune system includes the primary lymphoid organs (thymus, bone marrow, and probably liver) and the secondary lymphoid organs (lymph nodes, spleen, and gut-associated lymphoid tissue ). The functions of the immune system are basically two types: nonspecific and specific. Nonspecific immune defenses are activated on exposure to any foreign substance but react similarly regardless of the type of antigen; they are unable to identify the antigen. The principal component of this system is phagocytosis, the process of ingesting and digesting foreign substances. Phagocytic cells are composed of neutrophils and monocytes.

Specific  defenses are those that have the ability to recognize the antigen and respond selectively. The com¬ponents of adaptive immunity are humoral immunity and cell-mediated immunity. The cells responsible for these two forms of immunity are the lymphocytes, specifically B-lym-phocytes and T-lymphocytes.

 

Humoral immunity

Humoral immunity is involved with antibody production and complement. The principal cell involved in antibody production is the B-lymphocyte. In humans the exact site of production of the B-lymphocyte is speculative, although it is probably the bone marrow. In chickens the site is clearly identified as a hind-gut organ known as the bursa of Fabricius, hence the term “B-lymphocyte,” or “B-cell.” When challenged with an antigen, B-cells divide and differentiate into plasma cells. The plasma cells produce and secrete large quantities of antibodies specific to the antigen. Five classes of antibodies or immunoglobulins (lg) have been identified: G, M, A, D, and E, each serving a specific function .

On initial exposure to an antigen, the B-lymphocyte system begins to produce antibody, predominantly lgM, which appears in 2 to 3 days. This process is referred to as the primary antibody response.

With subsequent exposure to the antigen, a secondary antibody response occurs. Antibody, chiefly lgG, is produced in much greater quantities within I to 2 days. An example of the secondary response is consecutive administration of immunizations, often called boosters. Memory B-cells allow the immune system to recognize the same antigen for months or years.

When antibody reacts with antigen, they bind to form an antigen-antibody complex. This binding serves several functions. Antibody aids in the phagocytosis of antigen by sensitizing it in such a manner that it is more readily destroyed by phagocytes, a process known as opsonization.

Antibody also activates or fixes complement, the second component of humoral immunity. The complement system is a series of nine major factors (Ci and 09) present in serum that results in a cascade of enzymatic actions and death of a viable antigen. It also serves to bridge cellular and humoral immunity. After being activated by antibody, complement produces a chemotactic factor that summons T-lymphocytes and macrophages to the antigen site.

 

Cell-mediated immunity

Cell-mediated immunity is involved in a variety of specific functions mediated by the T-lymphocyte. The T-lymphocyte is so named because it passes through the thymus during the differentiation process, which leads to the mature T-cell. T-lymphocytes do not carry typical immunoglobulins on their surfaces as do the B-cells. However, they are functionally heterogenous in that several subsets have been identified, including cytotoxic T-cells, memory T-cells, helper T-lymphocytes, and regulator T-lymphocytes.

Specific functions of T-lymphocytes include: protection against most viral, fungal, and protozoan infections and slow-growing bacterial infections, such as tuberculosis, rejection of histoincompatible grafts, mediation of cutaneous delayed hypersensitivity reactions, such as in tuberculin testing, and probably immutie surveillance for malignant cells. In addition, they also have regulatory functions within the immune system. For example, helper  T-lymphocytes assist B-lymphocytes and other types of T-cells to mount an optimum immune response.

The cellular immune response is initiated when a T-lymphocyte is sensitized by antigen. In response to this contact the T-cell releases numerous humoral factors called lymphokines, which eventually bring about death of the antigen. For example, chemotactic factor promotes the migration of phagocytes and other T-lymphocytes to the antigenic area, migratory inhibitor factor prevents their leaving the site, transfer factor transforms nonsensitized T-cells into sensitized T-lymphocytes, blastogenic factor initiates the rapid mitosis of sensitized T-cells, and macrophage activation factor transforms local macrophages to highly phagocytic cells. Another lymphokine is interferon, which nonspecifically inhibits viral replication, promotes phagocytosis, and stimulates the killer activity of sensitized lymphocytes.

The immunologic properties of the mucosal lining of the gastrointestinal tract are immature, which predisposes this system, like the respiratory system, to increased risk of in¬fection and inflammation.

The immunologic system undergoes numerous changes during the first year. The newborn receives significant amounts of maternal lgG, which confers immunity for about 3 months against antigens to which the mother was exposed. During this time the infant begins to synthesize his own lgG, and about 40% of adult levels are reached by I year of age. Significant amounts of lgM are produced at birth, and adult levels are reached by 9 months of age. The production of IgA, lgD, and lgE is much more gradual, and maximum levels are not attained until early childhood.

The defense mechanisms of the tissues and blood, particularly phagocytosis, are much more efficient in the toddler than in the infant. The production of antibodies is well-established. Immunoglobulin G (lgG), which neutralizes microbial toxins, reaches adult levels by the end of the second year of life. Passive immunity from maternal transfer disappears by the beginning of toddlerhood, necessitating the use of artificial immunizations. Immunoglobulin M (lgM), which responds to artificial immunizing techniques and combats serious infection, attains adult levels during late infancy. Immunoglobulins A, D, and E increase gradually, not reaching eventual adult levels until later childhood. Many young children demonstrate a sudden increase in colds and minor infections when entering nursery school or kindergarten because of the exposure to new antigens.

 

Severe combined immunodeficiency disease

Severe combined immunodeficiency disease is characterized by absence of both humoral and cell-media immunity. The terms “Swiss type lymphopenic agamr globulinemia,” an autosomal-recessive form of disease, s “x-linked lymphopenic agammaglobulinemia” have be used to describe this disorder, which, as the names imp can follow either mode of inheritance.

Pathophysiology

The exact cause of SCID is unknown. The theories i elude (1) a defective stem cell that is incapable of differe: tiating into B- or T-cells, (2) defective organs responsib for the differentiating process, primarily the thymus ar lymphoid complex, or (3) an enzymatic defect that supresses lymphocytic cell function.

The consequence of the immunodeficiency is an ovei whelming susceptibility to infection and to the graft-vs-hoi reaction. The latter occurs when any histoincompatible tis sue from an immunocompetent donor is infused into the im munodeficient recipient. Because of its immunodeficiency the body is unable to reject the foreign incompatible tissue There fore, the antigenic donor cells attack the host’s tissues. The graft-vs-host reaction is a serious complication in the only known treatment for SCID, bone marrow transplant.

Clinical manifestations

Obviously the most common manifestation is susceptibil¬ity to infection early in life, most often by 3 months of age when maternal immunity is low. Specifically the disorder in children is characterized by chronic infection, failure to completely recover from an infection, frequent reinfection, and infection with unusual agents. In addition, the history reveals no logical source of infection. Failure to thrive is a consequence of the persistent illnesses.

If the child should receive a foreign tissue, such as blood supplements, signs of graft-vs-host reaction, such as fever, skin rash, alopecia, hepatosplenomegaly, and diarrhea, are expected. Since the reaction requires 7 to 20 days for tissue damage to become evident, the symptoms may be mistaken for an infection. However, the presence of a graft-vs-host reaction increases the child’s susceptibility to overwhelming infection and, therefore, is a grave complication.

Diagnostic evaluation

Diagnosis is usually based on a history of recurrent, se¬vere infections from early infancy, a familial history of the disorder, and specific laboratory findings, which include lymphopenia, lack of lymphocyte response to antigens, and absence of plasma cells in the bone marrow. Documentation of immunoglobulin deficiency is difficult during infancy be¬cause of the normally delayed response of the infant to pro¬duce his own immunoglobulins and maternal transfer of im-munoglobulin G.

 

HIV infection

Acquired immunodefidency syndrome (AIDS) is a rowing problem in the pediatric population Many IIV-infected children are asymptomatic, have only lild symptoms, or have AIDS-related complex ARC).

About 80% of infected children acquire the virus crinatally from an infected mother. Blood transfusions (between 1978 and 1985) and factor concen-•ates are responsible for most of the remaining casesa small percentage of pediatric cases, the mode f transmission is sexual, drug related, or unknown ecause an adequate history is not available. In in-tances of perinatal transmission, the most common isk factors or behaviors in themother are intravenous lrug use or heterosexual contact with a bisexual or ^ug-using partner, drug use in either parent accounts xmore than 70% of perinatal transmission. Perinatal JDS occurs more commonly in blacks (about 60% if cases) and Hispanics (25%).

 

Clinical Findings •

Children with HIV infection present to the ED with a wide spectrum of initial presentations and asso¬ciated complications. Many who live in chaotic social environments use the ED as their primary source of medical care. Table 125-1 indicates the most common presentations of HIV infection in children.

The typical case of pediatric HIV infection is a child born to a mother at risk who develops recurrent bac¬terial infections, thrush, failure to thrive, lymphade-nopathy, and hepatosplenomegaly in the first few years of life. However, both those who acquire HIV perinatally and those who acquire infection by trans-fusion may not present with symptoms until several years of age.

 

BACTERIAL INFECTIONS

The types of infections are similar to those in patients with hypogammaglobulinemia. Infections with the encapsulated organisms, Haemophilus influenzae type B, Streptococcuspneumoniae, and enteric gram-negative rods are common and can cause chronic or recurrent otitis media, pneumonia, lymphadenitis, bacteremia, mastoiditis, and meningitis. Malignant external otitis, a disease usually seen in older patients, also occurs. Other common conditions include der¬matitis, particularly eczema; in those patients Staph-ylococcusaureusts also an important pathogen. Sal-monella infections can be quite severe and may cause prolonged gastroenteritis or bacteremia; frequent re¬lapses may occur.

 

RESPIRATORY INFECTIONS

Pulmonary infection is a common and serious man¬ifestation of HIV infection. The most commonly di¬agnosed infection is Pneumocystis carinii pneu¬monia (PCP), which can present acutely with respiratory distress or with a history of progressive cough and respiratory symptoms over days to weeks. Clinically, it may be difficult to distinguish PCP from more typical causes of childhood pneumonia. The chest x-ray typically shows a diffuse interstitial pneu-monitis, although almost every pattern of infiltrate has been seen with PCP.

A second common pneumonitis is lymphoid in¬terstitial pneumonitis (LIP); the cause is unknown. Children with LIP often have a longstanding history of pulmonary symptoms, particularly cough. They are usually not febrile or acutely dyspneic, and rarely have significant auscultatory findings. A concomitant infection can cause a child with pre-existing LIP to present acutely. LIP is most often seen in children with other lymphoproliferative manifestations of HIV such as lymphadenopathy and parotitis; these patients may have signs of chronic pulmonary disease such as clubbing. The chest x-ray shows a diffuse interstitial infiltrate similar to that seen with PCP, but in some longstanding cases there may be a diffuse nodular pattern with widening of the superior mediastinum and hilum. LIP is currently a diagnosis of exclusion.

In addition to PCP and LIP, other routine and op¬portunistic infections must be considered in an HIV-infected child with respiratory distress. Bacterial

pathogens are frequent. Another common pathogen is respiratory syncytial virus (RSV), an extremely common viral infection in young infants and children, which can cause giant cell pneumonia in the com¬promised host. Cytomegalovirus can be cultured from the lung in these patients, although it is not always clear that it is the primary pathogen. Other oppor¬tunistic pulmonary infections are also in the differ¬ential diagnosis, including atypical mycobacteria and fungi.

 

CENTRAL NERVOUS SYSTEM DISORDERS

CNS disorders are a prominent part of the clinical spectrum of HIV infection in children. Encephalop¬athy, either static or progressive, is ofteoted. Man-ifestations often include acquired microcephaly, progressive motor dysfunction, loss of developmental milestones, ataxia, and extrapyramidal rigidity. Iso¬lated seizures are unusual but may occur with a con¬comitant febrile illness. Focal neurologic signs are uncommon in pediatric AIDS and should suggest possible CNS lymphoma. Opportunistic infections, particularly cryptococcal meningitis, may be present in the child with CNS symptoms. However, in most series of children dying with HIV encephalopathy, opportunistic infection of the CNS is rare, and most signs and symptoms are secondary to HIV infection of the nervous system.

GASTROINTESTINAL ILLNESS

 

Gl illnesses, especially diarrhea, are a major problem for HIV-infected patients. Salmonella can be a per¬sistent problem, particularly in patients with blood or mucus in the stool. Severe or prolonged diarrhea in pediatric AIDS patients also occurs with parasitic enteric pathogens, most notably Glardia lamblia, and cryptosporidium. In some instances, even after ex¬tensive evaluation, no specific etiology can be found to account for the diarrhea.

 

OTHER ENTITIES

Many of the usual childhood infections are seen in HIV-infected patients, but they may present in a more severe form. Oral candidiasis (thrush) is extremely common, particularly in infancy. HIV-infected pa¬tients often have extensive thrush, in the absence of previous antibiotic therapy. Infection may extend to the esophagus or the larynx and is resistant to the ” usual forms of therapy. Viral diseases such as herpes simplex, varicella, and measles can be quite aggres¬sive in HIV-infected children. Herpes simplex may cause prolonged or recurrent ulcerations and varicella may disseminate to cause pneumonia, encephalitis, r hepatitis. Measles can also cause a severe pneu-monia; the first measles deaths in the United States jto several years have recently occurred in HIV-in-lected children.

‘ A unique feature in pediatric HIV infection is the •elopment of parotitis. This can be chronic, with v, progressive, painless growth, or it can be acute, xiated with rapid enlargement, fever, and pain. he etiology is unknown.

f, A number of other entities described in pediatric ihiv infection are also important to recognize. These ^Include a nonspecific hepatitis, cardiomyopathy, and I the nephrotic syndrome. f Hematologic syndromes are also well described; jtilrombocytopenia is the most common, but anemia, I secondary to hemolysis, and neutropenia can be seen.

Clinical Evaluation and I Ancillary Data

I Use an aggressive diagnostic approach, because many  of the acute illnesses are treatable. For example, a I child with HIV infection who presents with fever is I quite likely to have a bacterial infection; obtain a I complete blood count (CBC), blood culture, urinal-j ysis, and chest x-ray if there is no obvious source of I fever on examination. Other imaging studies such as I sinus films may be indicated. If the child has a history I of neutropenia or is receiving azidothyrnidine (AZT), j the absolute neutrophil count may be depressed, I which would influence therapeutic decisions. I The new onset of pulmonary symptoms requires a I thorough evaluation. Although many of these patients I may not have an easily treated form of pulmonary I disease, early therapy is important. Because it is dif-1 ficult to clinically differentiate the common forms of I pneumonia in pediatric AIDS patients, hospitalization f is often required. In such patients, the initial diag-1 nostic tests include chest x-ray, CB^, blood culture, I and, in the appropriate epidemiologic setting, na-Isopharyngeal swabs for immunofluorescence or cul-j ture.

I Weight loss and diarrhea may be acute or chronic I and are often quite severe. In addition to routine I bacterial culture, obtain stool for ova and parasites. I Assess the patient’s state of hydration clinically and I measure serum electrolytes, blood urea nitrogen, and jcreatinine, since enormous fluid losses and profound I electrolyte imbalances are sometimes present. I CNS symptoms and physical signs will determine I whether lumbar puncture or scanning is appropriate. I If a spinal tap is performed, obtain more fluid than I necessary to diagnose bacterial meningitis, because {additional tests are often indicated, such as a culture for acid-fast organisms, viral culture, and cryptococcal antigen. If focal neurologic signs are present, arrange for a CT scan to evaluate for lymphoma or toxoplas-mosis.

Treatment and Disposition •

The treatment plan and the decision to hospitalize the patient must be made in conjunction with the family; many families want aggressive diagnostic and therapeutic plans, while others may prefer to keep medical intervention limited, with the goal of making the patient comfortable.

Consider hospitalizing HIV-infected patients with fever without a focus of infection, recent onset of pulmonary or CNS manifestations, or severe failure to thrive or diarrheal disease.

Patients who are not acutely ill and do not require hospitalization may require antibiotic therapy. If a focal infection is identified, such a sinusitis or otitis media, and there is no evidence of bacterernia, the patient can ordinarily be managed as an outpatient. However, a longer duration of therapy is required; for example, treat sinusitis for a minimum of 3 we6ks.

In cases of possible bacterernia, the antimicrobials must be effective against the encapsulated organisms and the enteric gram-negative rods.

For any HIV-infected patient who does not require hospitalization, arrange for the necessary follow-up of the acute problem with the primary physician and make appropriate referrals for long-term manage¬ment. Because of the chronic and complex nature of pediatric HIV infection, non-urgent problems are best handled in the calmer, more familiar outpatient office or clinic, not the ED.

Isolation techniques are based upon the mode of transmission of the disease .