Paediatric-History taking & Physical examination on Cardiology Case

Paediatric-History taking & Physical examination on Cardiology CaseCreated OnMay 22, 2020Last Updated OnMay 22, 2020byadmin You are here: Main Clinical Examination Paediatric-History taking & Physical examination on Cardiology Case < All Topics Table of Contents Chief complain: 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 for the previously diagnosed disease with duration. 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. 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 cardiology cases: Breathlessness during feeding or on exertion Sweating Rapid breathing Bluish discolouration/cyanotic spells Syncope Swelling in the lower limbs, abdomen or around the eyes Poor weight gain, greater than expected caloric intake Chest pain, palpitation Joint pain, fever, skin lesions Easy fatigability and irritability 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. 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. Past medical or 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 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. 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 / cardiac lesions detected during weeks of gestation. Prenatal screening was done due to suspicious findings of Down Syndrome. 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) Patient was noted to be syndromic at birth /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). Echocardiogram and other relevant investigations by paediatric cardiologist were performed and found to have details of the cardiac lesion. There was/was no history of admission to intensive care, oxygen or respiratory support provided. Nutritional 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. Currently, he/she drinks fluid including types of fluid and eats types of food including number of meals per day. There is/is no difficulty during feeding. 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. 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 development is/is not up to his/her age. *If the child is older, you may ask regarding the school performance to assess his or her development. It may be useful to compare the child’s progress and milestones with that of siblings and peer. 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 same condition, hypertension, congenital heart disease, sudden cardiac death or sudden infant death syndrome. **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, 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 RM xxxx. Example of General Examination and Cardiovascular Examination General examination: Name is a Chinese girl sitting up comfortably in bed and she is alert, conscious, coorperative and cheerful. There was no abnormal movement or posturing. She did not appear to be edematous, pale, jaundice, cyanotic or respiratory distress. There was no dysmorphic features. She is of medium build and growth chart is plotted with Height noted at 50th percentile and Weight at 50th percentile. There is a cannula inserted to her left dorsum of the hand and an ID tag is attached to her right wrist and she is not attached no any bedside instruments. Pulse rate was 105 beats/min with normal rhythm and normal volume. There was no radio-femoral or radio-radial delay. Pulse is not collapsed in nature. Blood pressure was 110/75 mmHg, respiration rate: 26 breaths/min, temperature: 0 deg Celcius and SpO2: 99% on Room air. Examination of skin revealed no rash, alopecia or neurocutaneous stigmata. Examination of hands – Both hands were warm and moist. The colour of the palmar surface of her hands appeared pink with no pallor. No signs of palmar erythema. No pallor in nail bed. Capillary refilling time was within 2 sec so is normal. There was no peripheral cyanosis. No evidence of clubbing. No signs of infective endocarditis such as Osler’s nodes, splinter haemorrhages, or Janeway lesion present. Koilonychias and leukonychia were absent on the nails. No rashes along the hands, forearms and arms of both left and right side. No flapping tremors seen. Examination of head and neck revealed symmetrical face with no scars. Inspection of the eye revealed that there is no sign of jaundice or pallor. The eyes were not sunken or edematous during examination. There are no signs of glossitis or central cyanosis. Her throat doesn’t appear to be injected, no exudates. There was no nasal flaring. Lips did not look dry. There was...

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