Paediatric-History taking & Physical examination of musculoskeletal case

Paediatric-History taking & Physical examination of musculoskeletal caseCreated OnApril 30, 2020Last Updated OnApril 30, 2020byadmin You are here: Main Clinical Examination Paediatric-History taking & Physical examination of musculoskeletal case < All Topics Table of Contents Chief complaint: (Name) is a (age) year-old (gender) with underlying (any disease diagnosed) was brought to hospital with the chief complain of (presenting symptom) for (duration). *Race is mentioned if it is relevant to the disease History of presenting illness: Patient was previously well until (onset of disease) when he/she developed or her/his parents noticed that (presenting symptom). The (presenting symptom) occurs at (acute/insidious) onset. If occurs at joint, specify which joints, how many joints involved. It was precipitated by (precipitating factors) and relived by (reliving factors). It is associated with (associated symptoms). If there is pain, describe the pain. The pain occurs at (acute/chronic) onset, and it is (continuous/intermittent) in nature. It is (localized to any joint/generalized to whole body). It (radiate/does not radiate) to other part of the body. The pain is characterized as (dull/throbbing/pricking) in nature. It is aggravated by (aggravating factors) and relived by (reliving factors). The pain is associated with (any associated symptoms). He/she graded the severity of the pain as (pain score). He/she was given (any intervention given – eg brought to clinic or given OTC medication) but (presenting symptom) (does/does not resolve). Due to (worsening/symptom not improving by treatment), he/she was brought to hospital for further evaluation. This is his/her (first time) of developing (presenting complain) / patient has had similar episode of (presenting complain) (when) and was treated (treatment given, where, by who). (Negative relevant – eg family history of or any risk factors contributing to the development of the symptoms) For child with underlying disease: Patient was previously diagnosed with (disease) when he/she presented with (presenting symptom at that time) at the age of (age). The diagnosis was made by (conformational investigation done) at (where and by who). Since the diagnosis, he/she was treated with (treatment given) and under regular follow up (how frequent and where). Patient is compliant to treatment and follow up. Recent follow up was (date) and (finding during follow up). There was (complications/no complications) from the disease or the treatment. Systemic review: General – fever, weight loss, loss of appetite, fatigue, malaise Cardiovascular – chest pain, dyspnea, orthopnea, syncope Respiratory – dyspnea, chest pain, cough Neurological – weakness, paralysis, numbness, incoordination, gait disturbance Gastrointestinal – altered bowel habit, nausea, vomiting Genitourinary – increase urgency, frequency, dysuria, incontinence Head, eyes, ear, nose, throat (HEENT) – dysmorphism, red eyes, change in vision, loss of hearing, dental problem Musculoskeletal – pain, deformity, gait disturbance, swelling, redness Past medical history: He/she (has/does not have) significant past medical history. If patient has underlying disease, describe further. He/she was diagnosed with (disease) (when, where and by who). He/she was admitted (where) for (duration of admission) and was treated with (treatment given). He/she was discharged after (duration) with (complete resolution or residual disease). If he/she had past surgical history, describe similarly – he/she was diagnosed with (disease) and had underwent (type of surgery) (with/without) complication. Drug history: He/she is (taking/not taking) any drugs or medications. If taking medication, mention who prescribed the drug, name of the drug, indication, dosage, frequency, patient’s compliance to the drugs. He/she has (no/known) allergy to (medication/food). Birth history: Antenatally, his/her mother was (well/not well) throughout pregnancy. His/her mother was (age) years old at the time of pregnancy. She (attended/did not attend) regular check-up and pregnancy 9was/ was not) eventful. If it was eventful, describe the condition, diagnosed at how many weeks of gestation, treatment given. She (take/did not take) folic acid/obimin prior to or during pregnancy. There (was/was no) gross abnormalities detected during antenatal scan. There (was/was no) history of exposure to radiation, alcohol or illicit drug during pregnancy. There (was/was no) detailed scan or triple screening done. Patient is (term/preterm) baby, delivered at (weeks of gestation) at (where). He/she was delivered by (method of delivery). If not 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 DDH, Down syndrome, and clubfoot. How diagnosis was made and further intervention given. Nutritional history: Patient is (breastfed/bottle fed) for (duration). Describe the frequency of breastfeeding. For formula milk, mention the name of the milk, amount including number of scoops and volume of water and frequency. Patient started weaning at (age) where he/she started eating (type of food, amount, frequency). He/she (is/is not) a picky eater. If picky eater, mention the food that the child refuses to eat. Immunization history: His/her immunsation history is up to date according to the Malaysian Ministry of Health guidelines. His/her latest immunsation 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 achieve (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, 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 (have/do not have) medical illness. 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 of malignancy or inherited disease – eg bone tumor, Marfan syndrome, and scoliosis. 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. Example of physical examination: General examination On inspection, the child was (lying down/sitting) on the bed. He/she (was/was not) comfortable, irritable, responsive to surrounding. He/she appears (well/not well) – any sign of respiratory distress or pain. Note the vital signs. Mention any bedside apparatus seen –eg orthosis, walking aids. He/she is of (thin/medium/obese) build. Record height and weight; plot on growth chart and comment – within what percentile. There (was/was no) neurocutaneous stigmata noted – eg café au lait, shagren patches. Mention dysmorphic features...

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