Pediatric history and physical examination. Dr. György Fekete - PDF

Pediatric history and physical examination Dr. György Fekete Different attitudes of visits Sick visit: acute disease Routine, preventive care In case of acute, emergency disease: start with history of

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Pediatric history and physical examination Dr. György Fekete Different attitudes of visits Sick visit: acute disease Routine, preventive care In case of acute, emergency disease: start with history of present symptoms! Good history taking adapts itself to the actual situation Privacy, confidence Hospital is committed to respecting and protecting the rights of patients and families. The privacy of the child's health information is very important and it is important to make every effort to ensure that it is kept confidential. History Personal data Presentation symptom Main complain History of present disease Therapies, medicines Allergic diseases Vaccination history Neonatal history Pregnancy history of mother Family history Previous diseases / surgical operations Developmental history Social/ environmental history Personal data Name Birth date Address Mother s name Father s name Child s pediatrician Presentation symptom Main complain Presentation symtoms: cause of referral at doctor s office ( vomiting, cough, seizure,etc.) It is not a diagnosis! Initial complain Duration Progress Referral to doctor/ hospital Doctor s action Medication, effect of medication History of present disease General condition of patient before this illness Trauma, accident just before? Vaccination? Immunization status? Note: check in the health- booklet of the child! Fever? Medicines, previous administration? Contacts with ill individuals? Travels? Medications Any chronic disease which needs to be treated continuously? Dosage? Previous side effects? Allergy? Compliance? Allergy history Food allergy? Drug allergy? Inhalant allergy? Other? Neonatal history Authentic source of information: medical report of hospital where the child was born Full term pregnancy? Premature birth at weeks Where was the child born? Type of delivery Birth weigth Birth length Head circumference Chest circumference Apgar score APGAR scoring chart Neonatal history Neonatal jaundice? Any congenital malformation? Any complication after delivery? Neonatal screening for inborn errors of metabolism done in the hospital? Pregnancy history with this child Did the mother take hormones during pregnancy? Did the mother take any drugs during pregnancy? Did the mother smoke during pregnancy? Did the mother drink any alcoholic beverages during pregnancy? Has the child s mother had any miscarriages, still births, or abortions? Past illnesses Infectious diseases Asthma Congenital heart disease Respiratory tract infections Urinary infections Neurologic disorders Others Child s development List age of child when the following milestones were reached: Sat alone at months Walked at months Words at months Sentences at months Child s development Breast fed Bottle fed Details of feeding Feeding problems Weigth, height gain Child s development First teeth at months Bladder trained at months Bowel trained at months Does the child have any handicap? Is there a bed-wetting problem? School performance Scholastic performance: academic, behavior Has child ever been in a special education class? Has the child had a learning problem? If yes, what type of learning problem? Hospitalisations and operations Appendectomy Tonsils and adenoids Ear tubes Others Family history History has to include first degree relatives Similar disease(s)? Related disease(s)? Infant death/ miscarriages? Congenital malformations? Genetic diseases? Any sisters, brothers? Social/ environmental history Marital status of parents: Married /single Has there been a separation, divorce or death? What has been the attitude of the child to this situation? Type of house/ appartement Any pet animal? With whom does the patient live? (List all household members and their relationship to patient.) Physical examination Initial: hand washing, introduction Vitals, anthropometric measurements, plotted on the chart Examine the child on a position that suits the child Infant: remove all clothing Adolescents: due respect to privacy and sensitivities Newborn Apgar score Insertion of tube thru nose - immediate diagnosis: esophageal atresia Note: life- threatening to feed the newborn with esophageal atresia! Dubowitz scoring Physiologic weigth loss: maximum 10% of birth- weigth Newborn Observe: breathing, body proportions, movements Head: sutures, anterior fontanel, major and minor abnormalities of skull and face Microcephaly+ smooth philtrum: important sign of fetal alcohol syndrome Anterior (great) fontanel closes till the age of 18 months Eyes (red reflex, strabismus) Ears, nose Skin (turgor, color, dermatologic signs) Gluteal erythema, mostly caused by Candida albicans Lymph nodes Musculo-sceletal system, joints (hips: dyslocation?) Newborn Heart (pulse rate: / min) Lungs (breath rate: 40-60/min) Abdomen (liver is palpable) Genital organs (boys: undescended testes) Anus and rectum Neurology (reflexes:moro, step,etc.) Step reflex is physiologic up to the age of 4 months Mouth (tongue, throat, bucca)
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