Paediatric-Template for History taking for abnormal Growth and Development

Paediatric-Template for History taking for abnormal Growth and DevelopmentCreated OnApril 21, 2020Last Updated OnApril 22, 2020byadmin You are here: Main Clinical Examination Paediatric-Template for History taking for abnormal Growth and Development < All Topics Table of Contents Chief Complaint: Name is a age year-old boy/girl from where with underlying any known diseases was brought to/presented to the hospital with a chief complaint of presenting symptoms with duration (in sequence)/ parent’s concern of delay in development. History of presenting illness (HOPI) + development history: He/She was previously well until when he/she was age years old, his/her parents realised that the child was not able to skills in one of the 4 domains of developmental milestones (eg. Walk). Ask relevant history based on the affected domains of developmental milestones Gross motor: The child was first noticed to be unable to skills in one of the 4 domains of developmental milestones by parents when and how they noticed. The child is mobile and gets around by crawling, cruising, or requiring assistive walking device OR The child is immobile and gets around by a wheelchair. The child generally appeared to be stiff/ laxed. There are/ aren’t any associated symptoms (such as abnormal jerky movements, twisting movements, fitting episodes, etc). The symptoms progressively worsened/ improved/ remained stagnant. There are/aren’t also no symptoms of possible complications associated with the disease. Vision & fine motor: The child was first noticed to be unable to skills in one of the 4 domains of developmental milestones by parents when and how they noticed. The child appears to be interested/ uninterested to the surrounding, and there is/ isn’t lack of smiling to appropriate stimuli. Apart from that, there are/ aren’t any symptoms of associated to the disease (eg. Squint, drooping of eyelid, watery eyes, nystagmus. There is/ isn’t any previous diagnosis of near-/ far sightedness. There are/aren’t also no symptoms of possible complications associated with the disease. Hearing/ speech/ language: The child was first noticed to be unable to skills in one of the 4 domains of developmental milestones by parents when and how they noticed. The child does not respond to call. There are/ aren’t any associated symptoms (such as ear pain, discharge, poor balance, etc). The symptoms progressively worsened/ improved/ remained stagnant. There are/aren’t also no symptoms of possible complications associated with the disease. Social/ emotional/ behavioural: The child was first noticed to be unable to skills in one of the 4 domains of developmental milestones by parents when and how they noticed. The child does not respond to call. There are/ aren’t any associated symptoms (such as hyperactivity, irritability, inattentive, poor eye contact, etc). The symptoms progressively worsened/ improved/ remained stagnant. There are/aren’t also no symptoms of possible complications associated with the disease. In conclusion, his/her developmental milestones are/ are not appropriate to his/ her chronological age If the child was previously diagnosed with a chronic disease, an undergoing active disease or a genetic disease such as Down syndrome, that is related to current presentation: The child was previously diagnosed with chronic/active/genetic disease when he/she was age during onset of diagnosis years old at where (hospital/clinic) by who (doctor). He/she presented with presenting symptoms at onset of diagnosis. He/she was investigated, and the result was abnormal results of the diagnostic test. He/she was treated with treatment given and followed up at where and when (e.g. monthly). Patient had been compliant/not compliant to the treatment given and follow ups. The last follow up was on date of last follow up. He/she did not suffer/suffered from any complications of the disease or treatment given. **you may consider adding in information regarding how the illness has affected the family or the child’s life (such as school performance) Review of systems: Cardiovascular system: rapid breathing on exertion, shortness of breath, palpitation, cyanosis during feeding Respiratory system: rapid breathing, productive/ dry cough, wheezing, haemoptysis Gastrointestinal system: reduced oral intake, vomiting, diarrhea, abdominal pain/ distension, constipation, jaundice Genitourinary system: reduced urine output, haematuria, crying during micturition, changes in frequency, amount or colour of urine Central nervous system: irritability, headache, fit, weakness, pain, incontinence, loss of consciousness Musculoskeletal system: joint pain, joint stiffness, joint deformities, joint swelling, difficulty ambulating Integumentary system: rashes, dryness, pigmentation, itching, discolouration Ophthalmology: red eyes, watery eyes, blurring of vision, diplopia Ear, Nose, Throat:  ear discharge, hearing loss, nasal block, hoarseness of voice Past medical history: Ask about previous development surveillance The child was previously on developmental surveillance and his/her developmental milestone at that time was outcome of previous follow up. He/she was managed with management plan of previous follow up. Currently there is / isn’t any improvements. The child was previously diagnosed with significant past medical problems at the age of age of diagnosis -month/ years old at where by who. Ask about admission history He/she was admitted for duration due to symptoms of past medical illness. During admission, he/she was treated with treatment given with complete resolution/ residual complications. Ask about follow-up history After being discharged, he/ she was/ was not given any follow up appointment. He/ she was given a follow up appointment how long days/ weeks after discharged and was required to follow-up how often. There were/were no episodes of similar symptoms. If the child previously underwent surgery He/ she underwent surgical procedure for indication of surgery without/ without complications. Otherwise, she does not have any relevant underlying chronic diseases. Drug History:  Focus on any drug taken and how it is taken in details The child has been taking/ took name of the medication with dose, route, duration for indication. He/she is/was compliant/ not compliant to the medications. Ask about any drug or food allergy He/she is allergic to name of medications or food substances as he developed allergic reactions such as reactions that took place as he/ she took the medications, or He/she has no known allergies. Ask about any supplements and traditional medicine taken He/she is not consuming any complementary or homeopathic medicine. (If yes, indications and type of medications should be asked and presented) If the child developed side effects or allergy, they must be mentioned too. Birth history: Ask about details of prenatal visit and birth in details His/ her mother was age years old during the pregnancy. The mother attended antenatal follow ups regularly and it was uneventful, or she suffered from illness or diseases (any endocrine diseases, other medical disease, or obstetric complications). His/her mother was taking folic acid/supplements/recreational substance at the time of conception and throughout the pregnancy. There were/weren’t any maternal illness (no fever, rash, gestational diabetes mellitus, hypertensive disorders, etc) during pregnancy, etc, (yes/no) exposure to drugs, smoking or alcohol, and no other complications during the pregnancy. There were also no foetal problems antenatally as well. The child was delivered at gestational week via spontaneous/induced vaginal delivery/assisted vaginal delivery/elective or emergency c-section with weight in kg at...

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