Paediatric-History taking & Physical examination for neurological case

Paediatric-History taking & Physical examination for neurological caseCreated OnApril 30, 2020Last Updated OnApril 30, 2020byadmin You are here: Main Clinical Examination Paediatric-History taking & Physical examination for neurological case < All Topics Table of Contents Chief complain: My patient is (name) (age) year/month old (race * if relevant) boy/girl was admitted/ was brought to hospital (when) with the chief complaint of (presenting symptoms) for (duration). *Mention important underlying condition such as Down’s syndrome History of presenting illness: My patient was previously well until (onset of disease) when he/she developed (presenting symptom). The (symptom) occurred at (acute/insidious onset). If patient presented with seizure, describe what the patient was doing at that time (eg sleeping, playing). The seizure was triggered by (factors – eg fever, sleep deprived, bright lights) or the seizure episode was preceded by (presence of acute disease- eg gastroenteritis, meningitis). During the seizure (describe the event – child was conscious/unconscious) and parents/caretaker noted (pattern of abnormal movement – eg jerking of the limbs, lip smacking) for (duration of the seizure). Patient gain consciousness after (duration of seizure) and he/she was (describe the condition – eg lethargic, drowsy). This is his/her (first episode/specify how many episodes). Mention any intervention at home (eg rectal diazepam and how the patient responds to treatment) *If patient has developed seizure in the past, mention when was the last time he/she had a seizure, any triggering factor and describe the event occurring during the seizure and control of the seizure. If patient presented with weakness, specify which limbs effected and level of weakness (eg unable to ambulate/limping). If patient presented with pain, describe the site, onset, characteristic (eg throbbing, pricking, dull) radiation to any part of the body, any relieving or aggravating factors, associated symptoms and severity of the pain. Patient was also (level of activity – irritable, less active, drowsy) and he/she (describe feeding pattern – eg reduced oral intake, refuse to take eat/drink). Therefore, his/her parents/caretaker brought him/her to (hospital/clinic) for further management. This is his/her first episode of (symptoms) or he/she has experienced similar complain (when and treatment given, where, by who). Include important negative relevant (eg family history, underlying diseases and any risk factors contributing to development of the symptoms). Summarize whether there is or there is no relevant finding from systematic review. Past medical history: Patient (has/has no) significant past medical history. If there is, describe the admission. eg patient was admitted at (where) when she presented with (presenting symptom). Investigation done (eg MRI/lumbar puncture) and he/she was diagnosed with (disease). Patient was admitted for (duration) and was treated with (treatment given). He/she was discharged (complete resolution or with residual disease) and patient was on (frequency of follow up, if any) date of previous admission, reason for admission, duration of hospital stay, any treatment or intervention given and any follow up. If patient had past surgical history, describe similarly – patient was diagnosed with (disease) and he/she underwent (type of surgery) (with/without complication) and was discharged after (duration of hospital stay). Drug history: Patient is currently taking/not taking any drugs/medications. If taking medication, mention who prescribed the drug, name of the drug, indication, dosage, frequency, patient’s compliance to the drugs and mention side effect of the drug. He/she (has/ has no) known allergy to (specify medication/food). Brith history: Antenatal history was/ was not eventful. If eventful, describe the condition and management for the mother – eg mother was diagnosed with (disease) at (how many weeks pregnancy) and was managed with (treatment). Patient was delivered (method of delivery – eg spontaneous vaginal delivery/elective C section/ emergency C section) at (weeks of gestation) at (place of birth). If patient was not born by spontaneous vaginal delivery, mention why. His/her birth weight was (birth weight). Upon delivery, patient was well/ was not well. If not well, describe the event – eg, low Apgar score, HIE, resuscitated. He/she (was/was not) admitted to NICU. He/she was diagnosed with any congenital problem –eg congenital hydrocephalus. Describe how diagnosis was made, any investigations and management of the condition. Nutritional history: Patient was (breastfed/bottle fed) for (duration). Describe the frequency of breastfeeding. For formula milk, mention the name of the milk, amount of milk consumed including number of scoops and volume of water and frequency of feeding. Patient started weaning at (age) where he/she started eating (type of food, amount, frequency). He/she is not a picky eater. If picky eater, mention the food that the child refuses to eat. Immunization history: His/her immunization history is up to date according to the Malaysian Ministry of Health guidelines. His/her latest immunization was at (age), which was (name of vaccination). There was (allergy/no allergy) reaction to the vaccination. Developmental history: For gross motor, patient was able to (gross motor – sitting without support, bear weight, walking, running) at (age) months/years old. For fine motor, patient was able to (fine motor – pincer grip, play with toys, scribble, draw) at the (age) months/years old. For speech and language, patient was able to (speech – vocalizing, form sentence) at (age) months/years old. For social development, patient was able to (social component – feed self, dry by day, play with friends) at (age) months/years old. According to his/her milestones, his/her development is (appropriate/not appropriate) to chronological age. Family history: His/her mother is (age) years old while his/her father is (age) years old. Both of them are healthy. If they have medical illness – describe the condition, duration, treatment, follow up and control of the disease. He/she has (how many sibling, age of the siblings and health status). Mention significant family history – eg history of seizure and epilepsy, any congenital diseases Social history: His/her father works as (occupation) at (place) while his/her mom is working as (occupation) at (place). Their basic salary is (salary) and they (do/do not) have financial problem. They live together in (address) in a (type of house –terrace or apartment). His/her parents (do/do not) smoke, take alcohol or consume illicit drug. If the parents do, mention about the number of cigarette sticks smoke per day and if there is exposure to the smoke to the child. Mention about recent travel history (when and where). Mention any sick contact at home or daycare. Physical examination: General examination My patient is (name, age, race *if relevant and gender). On examination, he/she is (level of activity – alert, conscious, drowsy, lethargic). He/she is lying comfortably/irritable. He/she appears to be in pain /respiratory distress (evidence of respiratory distress – eg tachypnea, accessory muscle usage). Observe for any abnormal movement. Mention presence of bedside instruments – eg oxygen, VP drainage. He/she appears well nourished – plot on growth chart and mention the centile for growth and height. He/she appears – describe appearance eg pale/jaundiced. On examination of the hand, there is no finger clubbing or peripheral cyanosis. Capillary refill time is within 2 seconds. The pulse rate is beats per minute, with regular rhythm and normal volume.  The respiratory rate is ___ . Describe any skin lesion – eg Shagreen patches, café au lait, Port wine stain. On examination of the eyes, there is no pallor & jaundice. Oral hygiene is good and there is no central cyanosis. Examine the fontanelle and describe – open/closed, bulging/sunken and any pulsation felt. Neurological examination On inspection of the limbs, describe the attitude of the limb – eg scissoring of the legs, frog like posture. Note for presence of scar, symmetry of the limbs and any muscle wasting or muscle hypertrophy seen. Observe for any abnormal movement – eg fasciculations, jerking, writhing movement. Comment about muscle bulk and symmetry. Both upper and lower limbs have good muscle tones – if abnormal tone (hypotonia/hypertonia) describe whether localized or generalized. Power is full in both upper and lower limbs – if there is weakness, specify the site of weakness and grade the muscle strength. Deep tendon reflexes/superficial reflexes are present – mention abnormality like hyperreflexia. In infant, check or primitive reflexes. There is/there is no ankle or knee clonus. Babinski is downgoing/upgoing. Sensation to pain, light touch, crude touch, vibration, propioception and temperature are intact in all dermatomes – if not intact, specify the dermatome and which sensation is lost. To complete the examination, I would like to perform cranial nerve examination (summarize if all cranial nerves are intact/mention any abnormality) and assess the developmental status (note for any delay in any component). General approach to a patient with neurological issue History taking: Ask about patient’s identification Age, gender, race and religion are important factor in some disease to diagnose. While factor of address is needed for treatment purposes. Name Age Gender Race Religion Address Date of admission Date of clerking Informant Ask about the chief complaint Chief complain is the major concern in neurology cases that brings the patient to visit the doctor. List down the complaint along with duration in chronological order. Listed below are some of the most common complaints. Headache It can be due to primary (migraines or tension-type headaches) or secondary most often associated with minor illnesses (viral upper respiratory infections or sinusitis), but may be the first symptom of serious conditions (meningitis or brain tumours). Seizures Acute symptomatic seizures are mostly secondary to an acute problem affecting brain excitability (electrolyte imbalance or infection). Definition of a seizure is a transient occurrence of signs or symptoms resulting from abnormal excessive or synchronous neuronal activity in the brain. Weakness It can be due to disorders of upper motor neurons or lower motor neurons. Weakness is defined as decreased ability to voluntarily and actively move muscles and can be either localized or generalized. Abnormal movements (ataxia) The most common causes of acute ataxia in childhood are post infectious acute cerebellar ataxia and drug intoxications. Ataxia is defined as an inability to coordinate muscle activity, causing jerkiness and incoordination. Loss of consciousness Acute changes of consciousness have varying degree from mild lethargy, confusion to deep coma. Most common causes of coma are due to toxin (Ethanol, barbiturates, antihistamines), infections (Meningitis, encephalitis, brain abscess), head trauma (Shaken baby syndrome, epidural haemorrhage, subdural haemorrhage), hypoxic-ischemia (cardiac arrest, near drowning) and seizure (postictal state, subclinical status epilepticus) Ask about history of presenting illness Headache Onset Acute, chronic, or episodic. Each pattern (acute, recurrent-episodic, chronic-progressive, chronic-nonprogressive) has its own differential diagnosis Tension-type headache last for hours or days. Migraine headache usually last 1 to 72 hours. Intermittent or continuous Location Where was the pain located or occipital frontal? TTH pain is commonly global. Pain TTH pain is commonly global. Migraine attacks the frontal or bitemporal. Character of the pain TTH pain is commonly and squeezing or pressing in character. Migraine pain is stereotyped or unilateral, moderate to severe, pounding or throbbing pain Associated symptoms Nausea, vomiting, fever, nausea, vomiting, phonophobia, or photophobia. Secondary headaches are most often associated with minor illnesses (viral upper respiratory infections or sinusitis). Tension type headaches have no associated nausea, vomiting, phonophobia, or photophobia. Migranine have associated symptoms which include nausea, vomiting, pallor, photophobia, and phonophobia Aggravating & relieving factors Seizures Details about the seizures first than any other symptoms. Differentiate the types of seizures. Start with asking the witness to describe the seizures from beginning to end. Then ask focused questions to ascertain details. If possible, they have video recording of the seizure. Characteristics of seizures in motor (stiffness or jerkiness), sensory (visual, auditory, olfactory, gustatory, vertiginous, somatosensory), psychic (déjà vu, fear) or autonomic abnormalities (lip smacking, chewing, rubbing of fingers, shuffling of feet). Simple seizures clinical symptoms may include motor (tonic, clonic, myoclonic), sensory, psychic, or autonomic abnormalities. Complex seizures have impaired consciousness on onset, psychic symptoms like déjà vu, or automatisms during complex partial seizure. In generalized seizures, tonic, clonic,...

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