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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:______________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

^ 2. Anamnesis morbi (present history)___________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

3. ^ Anamnesis vitae (past history) (Please ask different questions under 3 yr and older children):

__________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

^ Genealogical tree (family tree):




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________________________________________

__________________________________________________

^ Physical development estimation: whole conclusion: physical development of child is ____________________________________

Neuropsychological development: Level of development ____________________________________________________________

^ Nervous system investigation: special complaints (please specify): ____________________________________________________

___________________________________________________________________________________________________________

Local inspection: head:________________________________________________________________________________________

Vertebral column_____________________________________________________________________________________________

Other (please specify)__________________________________________________________________________________________

Syndrome of disorders: ________________________________________________________________________________________

^ SKIN EXAMINATION:

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?

^ SYNDROME OF DISORDERS:

  1. RASH:____________________________________________________________________________________________

  2. HAIR:_____________________________________________________________________________________________

  3. NAILS:____________________________________________________________________________________________

  4. LYMPATIC NODES__________________________________________________________________________________

  5. OEDEMAS:_________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

___________________________________________________________________________________________________________

Mark _______________________________________________Teacher_________________________________________________

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