Paediatric-History taking & Physical examination on endocrinological case

Paediatric-History taking & Physical examination on endocrinological caseCreated OnApril 28, 2020Last Updated OnApril 29, 2020byadmin You are here: Main Clinical Examination Paediatric-History taking & Physical examination on endocrinological case < 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 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 (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.   If the child was previously diagnosed with a chronic disease, an undergoing active disease or a genetic disease such as Down syndrome/ Turner syndrome, that is related to current presentation: The child was previously diagnosed with chronic/active/genetic disease when he/she was age during onset of diagnosis years old at where (hospital/clinic) by who (doctor). He/she presented with presenting symptoms at onset of diagnosis. He/she was investigated and the result was abnormal results of the diagnostic test. He/she was treated with treatment given, and followed up at where and when (e.g. monthly). Patient had been compliant/not compliant to the treatment given and follow ups. The last follow up was on date of last follow up. He/she did not suffer/suffered from any complications of the disease or treatment given. **you may consider to add in information regarding how the illness has affected the family or the child’s life (such as school performance) Systemic review: Cardiovascular system: rapid breathing on exertion, shortness of breath, palpilation, cyanosis during feeding Respiratory system: rapid breathing, productive/ dry cough, wheezing, haemoptysis Gastrointestinal system: reduced oral intake, vomiting, diarrhea, 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 was 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....

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