Passport part
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Student_____________________________________________ _____________________group _________date_______________ Passport part: Name of the child__________________________________________________________ward __________age________________ Mother age___ profession___________________________ Father age___ profession_____________________________________ School/kindergarten/Home/etc_____________________Date of entering the hospital______________________________________ 1. Complaints:______________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ^ ___________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ 3. ^ __________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ^
Age period:________________________________________ Whole inspection: Consciousness _____________________________________ Position in bed_____________________________________ Face expression ____________________________________ The reaction on your investigation (please specify)_________ Vital signs – normal or not____________________________ Whole state of health (satisfactory, mild, severe, greatly severe), why________________________________________ __________________________________________________ ^ hole conclusion: physical development of child is ____________________________________ Neuropsychological development: Level of development ____________________________________________________________ ^ : special complaints (please specify): ____________________________________________________ ___________________________________________________________________________________________________________ Local inspection: head:________________________________________________________________________________________ Vertebral column_____________________________________________________________________________________________ Other (please specify)__________________________________________________________________________________________ Syndrome of disorders: ________________________________________________________________________________________ ^ : 1. Special complaints for skin disorders: color changing, hair and nails problems (falling out etc), hyperhidrosis (sweating): whole, local (head or occiput), rash, oedemas____________________________________________________________________________ 2. This child is light-skinned or dark-skinned_______________________________________________________________________ 3. Skin color: normal pink, normal brown, normal yellow tone, red (erythematic), intensive red (plethora), pale, yellow (jaundice), violet (cyanosis), other________________________________________________________________________________________. 4. Primary rash elements (primary lesions): makula, urtika, vesicula, bulla, pustula, papula, tuberculum, nodus__________________ 5. Secondary rash elements (secondary lesions): erosio, excoriatio, rhandages, ulcus, cicatrix, squama, crustae, lichenificatio, pigmentationes_______________________________________________________________________________________________ 6. Subcutaneous adipose tissue: distribution (uniformly, nonuniformly), quantity (normal, increasing, decreasing).________________ 7. Hair and nails:_____________________________________________________________________________________________ 8. Skin palpation: humidity __________, temperature___________, elasticity________________, turgor_______________________ 9. Oedemas: where____________________________________________________________________, cold or hot, cardiac or renal. 10. Lymphatic nodes: size, quantity, mobility, underline tissues, sensitivity, consistence. Groups: occipital, ears back, submaxillary, chin, neck back, neck front, axillary, cubital, inguinal, popliteal________________________________________________________ 11. Skinfold thickness:_______________cm. Estimation_____________________________________________________________ Your conclusion (please underline): 1. Does the skin system damaged in your patient? 2. Does the patient have acute or chronic illiness? ^
___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________ Mark _______________________________________________Teacher_________________________________________________ |
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