Студент КГМУ: Заполнение истории болезни ребенка в стационаре. Диалог.

Заполнение истории болезни ребенка в стационаре. Диалог.


Заполнение истории болезни ребенка в стационаре.


T: Good morning. Today I'll tell you about the study of the disease in infancy and childhood.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
S: Are their any affections in childhood that differ from those of adult life. 
T: Sure and there are also many diseases typical of early life.                                                                                                                                                                                                                                                                                                                                                                             
S: Does the case history of a child differ from that of an adult. I believe the child's history is mostly obtained from a parent.   
T: You are right. In infant or even older child can't give an account of his painful sensations.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                              
S: What does the case history begin with?                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                            
T: The first point of the history should be brief statement of the present complaints and symptoms.
S: And what about the child's previous history. Is it necessary to discover the date, nature, and mode of onset and duration of all previous illnesses?
T: Of course. The child's previous history includes: family background, fetal development, neonatal life and landmarks of growth and development.
S: And what questions does the pediatrician usually ask?
T: The nature of the pediatrician's questions varies, of course, with the case.
S: I think that the state of general nervous system should be reviewed.
T: Yes, and the most important symptoms are restlessness, crying, sleeplessness, coughing, convulsions or pain.
S: And what must be taken into account in digestive disorders?
T: Well, the mode of onset and its nature are very important. Then pay attention to the history of vomiting or diarrhea, character of vomits of the stools, and, of course, appetite.
S: I see that the history of the pediatric patient is made up in much more complete detail and may require time and skill.