Paediatric-History taking & Physical examination for gastroenterology

Paediatric-History taking & Physical examination for gastroenterologyCreated OnApril 23, 2020Last Updated OnApril 23, 2020byadmin You are here: Main Clinical Examination Paediatric-History taking & Physical examination for gastroenterology < 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) or was admitted for further management. History of presenting illness: He/She was previously well until duration prior to admission (e.g. three days prior to the admission) when he/she developed acute/gradual onset of presenting symptom (details of past medical history maybe included if the current complaint directly relates to an ongoing chronic disease). The presenting symptom was precipitated by causes or precipitating factors. It was continuous/intermittent in nature. It was aggravated by aggravating factors, and relieved by relieving factors. The presenting symptom had progressively worsened/improved. This was the first time that the patient suffering from the condition/The patient had suffered from the same condition before. There were/were no other member of the family or friends with the similar symptoms. ** Present based on the presenting/ associated symptoms Abdominal pain: He/She complained of pain over the quadrant of the abdomen. The pain was described to be –characteristic of the pain (dull/ pricking/ colicky/ burning), sudden/ gradual in onset, non-/ radiating (if radiating, mention the site of radiation). The pain worsened by aggravating factors, and relieved by relieving factors. He/She rated the pain to be pain score out of 10. Vomiting: He/She presented with number of episodes of vomiting. The vomitus is content of vomitus, colour of vomitus, volume of vomitus, presence of blood. The vomiting occurred duration after eating. Diarrhoea: He/She presented with number of episodes of vomiting. The stool colour of vomitus, volume of stool (number of pampers used), presence of blood/ pus. Dehydration: He/She appeared to be lethargic/ energetic and less active/ active than usual. There was also reduced/ normal urine output (based on the number of pampers used). Systemic review: 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, diarrhoea, 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: The child was previously diagnosed with significant past medical problems at the age of age of diagnosis -month/ years old at where by who. 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. After being discharged, he/ she was/ was not given any follow up appointment. [If there is follow up] – 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: 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. 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. 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 due to the drugs taken, they must be mentioned too. Birth history: 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 no maternal illness (no fever, rash, gestational diabetes mellitus, hypertensive disorders during pregnancy, etc), no exposure to drugs, smoking or alcohol, and no other complications during the pregnancy. There were also no fetal problems antenatally as well. The child was delivered at gestational week via via spontaneous/induced vaginal delivery/assisted vaginal delivery/elective or emergency c-section with weight in kg at where with/without complications (e.g. birth trauma) There was/was no congenital malformations noted at birth. Postnatally, patient stayed in the hospital for duration with/without neonatal illnesses (feeding problems, jaundice, sepsis, hypoglycaemia, hypothermia). There was/was no history of admission to intensive care, oxygen or respiratory support provided. Developmental history: According to the parents, the child was able to gross motor function (sitting steadily, crawling, walking steadily) by the age of age years or months. For fine motor development, he was able to fine motor development milestones (feed self with hands, transfer object from hand to hand, scribbling) at the age of age years or months. For language development, he/she was able to language/speech development milestones (babbling, understand one word with meaning, understand phases with 2-3 words) at the age of age years or months. For social developmental milestones, he/she was able to social developmental milestones (smile, laughing, show stranger anxiety, mouthing, feed with spoon) at the age of age years or months. In conclusion, his/her developmental milestones are/ are not appropriate to his/ her chronological age Immunization history: The child has completed immunization up to his/her age according to the national immunization schedule. The last vaccination was date. He did not develop any reactions towards the vaccinations. (if yes, please ask the parent regarding the associated vaccine and the reactions) **If the child has not been vaccinated due to parents’ refusal, the reason of refusal should be explored and presented in the history. Feeding history: The child was exclusively breastfed or bottle-fed with expressed breast milk for duration. The child was breastfed for frequency and amount during each feeding. He/she weaned at age years/months old during when he/she was introduced with type of food including quality, quantity, meal frequency. If formula milk was given: He/she was bottle-fed with formula milk which the caretaker prepared by mixing number of scoops of milk powder and volume of water. He/ she drinks amount of ounces of formula milk frequency times a day. Currently, he/she drinks fluid including types of fluid and eats types of food including number of meals per day. Family history: The child’s mother is age years old while his/her father is age years old. Both his/her parents are well and healthy or suffering from medical illnesses. He/she has number of siblings whose ages ranging from youngest to oldest years old. They are well and healthy or suffering from medical illnesses. There is/is no history of consanguinity. There is/is no history of child born with congenital malformations or suffering from genetic disorders. There is/is no family members suffering from the same illness. **History of chronic diseases such as diabetes mellitus or hypertension, cancers or hereditary diseases should be mentioned if any. Social history: The child’s parents are working as parents’ occupation. His/her parents’ education levels are academic qualification. He/she is being mainly taken care of by caretaker. The child is living with who in a type of house including location (whether it is a dengue hotspot?), number of bedrooms and occupants. There is/is no issue such as substance abuse, marital instability, financial difficulty or family member who smokes. The monthly household income is amount of money. Physical examination: General examination Name is a age year-old girl sitting comfortably on the bed. She is conscious, alert, responsive to the surroundings, and cooperative. She is not cyanosed, pale or jaundiced; and there are no obvious features of dysmorphism seen. There is a name tag over the right wrist and a brannula on the dorsum of her left hand, secured with bandages, which is not connected to any intravenous drip at the time of examination. She does not appear to be in respiratory distress. Her blood pressure is reading mmHg, pulse is reading beats per minute with regular rhythm, good volume, no radio-radial delay), temperature is reading °C, respiratory rate is reading breaths per minute, spO2 is reading % under room air/ on type of O2 delivery device. Her height is measured to be reading cm (x th centile), weight is reading kg (x th centile), plotted on the growth chart. Examination of hands – Both palms appear to be warm, moist and pinkish. The nail bed appears to be...

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