Paediatric-History taking template on pediatric clerkship presentation for a child with rheumatic disease

Paediatric-History taking template on pediatric clerkship presentation for a child with rheumatic diseaseCreated OnApril 22, 2020Last Updated OnApril 22, 2020byadmin You are here: Main Clinical Examination Paediatric-History taking template on pediatric clerkship presentation for a child with rheumatic disease < All Topics Table of Contents Basic structure for case presentation: duration should ideally be around 8-10 minutes Chief complaint: Name is a age year-old boy/girl with underlying any chronic diseases or active diseases was brought to/presented to the hospital with a chief complaint of main presenting symptom with duration or was electively admitted for evaluation of presenting problem, or for follow up a previously diagnosed disease with onset of diagnosis   **Only include the race and ethnicity of the patient if it is relevant **Other information that maybe considered to add in – full name of each parent, contact details, address, date of birth 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. The presenting complaint also associated with joint swelling/joint pain/joint stiffness or gelling after period of inactivity/joint warmth/restricted joint movements/limping or gait abnormalities/instability. 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 such as juvenile idiopathic arthritis, that is related to current presentation: The child was previously diagnosed with chronic/active 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 or adjunctive 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. He/she has been ambulating without/with limitations with/without walking aids. He/she is ADL (activities of daily living – eating, bathing, getting dressed, toileting, transferring, continence) independent/dependent. Systemic review: Rheumatic disorders are multi-systemic. Hence, it is important to review other systems, especially the extra-articular manifestation: General – fever, recent weight change, activity level, ability to keep up with peers, anorexia, growth retardation Eyes – discharge, redness, puffiness, visual impairment (uveitis) Ear, nose throat – discharge, tinnitus, vertigo, reduced hearing, nasal congestion, epistaxis, sore throat, dysphagia Respiratory – breathlessness, cough, wheeze, hoarseness, hemoptysis, chest pain Cardiovascular – chest pain, breathlessness, palpitation, syncope, oedema, exercise tolerance Gastrointestinal – vomiting, abdominal pain or distension, frequency of bowel movements, jaundice Urinary – dysuria, frequency, urgency, nocturia, haematuria, menarche Neurological – altered consciousness, weakness, numbness, fainting, incoordination, tremors, seizures Musculoskeletal – deformities, pain, swelling, warmth, muscle cramps and weakness, gait changes Endocrinology – delayed puberty Integumentary system– rashes, itching, nail changes such as pitting Allergy – urticaria, hay fever, asthma, eczema **If the systemic review is unremarkable, just mention: the systemic review is not significant or unremarkable. Antenatal and birth histories: His/her mother was age years old during the pregnancy. The child was conceived naturally/by assisted reproduction. The mother was healthy throughout the gestation or suffered from illness or diseases (any antenatal infections or obstetric complications). His/her mother was taking prescribed medications/recreational substance at the time of conception and throughout the pregnancy. His/her mother was compliant/not compliant to the antenatal care. The fetal growth was normal/abnormal throughout the pregnancy. The child was delivered via spontaneous/induced vaginal delivery/assisted vaginal delivery/elective or emergency c-section at gestational week with birth weight of weight in kg at place of birth (hospital, home, birthing centre) with/without complications (e.g. birth trauma) There was/was no congenital malformations noted at birth. Postnatally, he/she stayed in the hospital for duration with/without neonatal illnesses (feeding problems, jaundice, sepsis, hypoglycaemia, hypothermia). There was/was no history of intensive care, oxygen or respiratory support provided. (abnormal neonatal screening test results should...

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