Paediatric-History taking & Physical examination of a patient with on Nephrology case

Paediatric-History taking & Physical examination of a patient with on Nephrology caseCreated OnApril 28, 2020Last Updated OnApril 28, 2020byadmin You are here: Main Clinical Examination Paediatric-History taking & Physical examination of a patient with on Nephrology case < All Topics Table of Contents Template on paediatric Nephrology Case Presentation Identification and 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 or patient came for follow up a previously diagnosed disease with duration/ abnormal urinalysis. History of presenting illness: He/She was previously well until duration prior to 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 aggravating 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/fluctuating course and patient rated the severity. 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. The symptoms/condition has severely disturbed patient’s daily activities. *Explore and describe each symptom. Enquire on possible risk factors, complications and rule out your list of differential diagnoses by asking specific symptoms related to the disease. Using the general format above, ask symptoms specific to renal cases: Abnormal voiding/storage pattern – timing, volume (oliguria/polyuria), dysuria, frequency, urgency, flow, hesitancy, urgency, enuresis Urine colour – red coloured urine, foamy urine Abnormal urine odour – foul smelling, underlying metabolic disorders Abnormal results of urinalysis – hematuria, proteinuria found Abnormal pain, mass or distension Edema – location Uremic symptoms – will be discussed in this chapter Symptoms of hypertension Weight changes – weight gain/loss Failure to thrive, loss of appetite Fever, rash Lethargy, fatigue, nausea, vomitting Systemic review: GIT- abdominal pain, diarrhea, constipation, vomiting, hematemesis, melena, jaundice, nausea and loss of appetite (the last two describe as poor feeding). Respiratory- Shortness of breath, noisy breathing, cough, hemoptysis, sputum. Cardiovascular- dyspnea, palpitation, cyanosis. Nervous system- headache, convulsions, abnormal movements, abnormal hearing or vision. Locomotor- joint pain and stiffness, joint swelling, abnormal movements, restricted movements. Hematology- epistaxis, bruises, patichae, bleeding from anywhere. Skin- dryness, discoloration, pigments, itching, rash, lump, hair and nail changes. ENT- sore throat, snoring, noisy breathing, ear-ache *If the systemic review is unremarkable, just mention that the systemic review is not significant. Antenatal and birth histories: His/her mother was age years old during the pregnancy. The mother was healthy throughout the gestation or suffered from illness or diseases (TORCHES infection, diabetes, hypertension). His/her mother was taking folic acid/supplements/recreational substance at the time of conception and throughout the pregnancy. His/her mother was compliant/not compliant to the antenatal care. Antenatal ultrasounds were done, there was no significant finding (renal agenesis, antenatal hydronephrosis, polycystic kidney disease or posterior urethral valve.) The fetal growth was normal/abnormal throughout the pregnancy. There was no exposure to radiation or cigarette smoking. The child was delivered via spontaneous/induced vaginal delivery/assisted vaginal delivery/elective or emergency c-section at gestational week 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. Past medical and surgical history: Patient was previously diagnosed with similar condition / significant past medical problems when she/he was age of onset of diagnosis at where by who. If the child was admitted – He/she was admitted to the hospital for duration, being treated with treatment given with complete resolution/residual complications. He/she had also been followed up frequency at where. If the child previously underwent a surgical procedure – He/she underwent surgical procedure (including timing) for indication of the surgery with/without complications. 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...

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