MEDICAL HISTORY
PAM F BIND Birth - any complications during or after pregnancy - was he delivered at term 37 weeks - how was delivered - any complications during delivery -alcohol drugs, during pregnancy - any infection during pregnancy Immunization o What is the immunization status of the baby? Can you please show me? o If on the phone, please bring you immunization card to the hospital? Nutrition o Howdoyoufeedyourchild?(breast/formula) when was solid food added o how is his eating Development: when was the last time you seen your ped did he say he was developing has been gaining weight properly, what about language, what about height daycare - any ill contacts -baby look -
FEVER
VO MUL GU
between 98.7°F and 100.4°F low grade - 37.5°C and 38.3°C
high grade 100.4°F/38°C
What do you mean by “burning up”?
For how long? Continuous or intermittent?) What is the reading? Oral
or rectal? last measured, chills/sweating, medications
How is the child look? (Lethargic, irritated or playful)
Viral illness Otitis Media meningitis URI (Croup high pitched breath sound, barking cough/epiglottis) LRI (bronchiolitis)- wheezing Gastroentritis UTI diagnosis sepsis- cbc w differentials, blood culture, U/A, and urine culture CXR - pnemonia pneumatic Otoscopy - otitis medal
SEIZURE
FM TE
Please tell me more about that? Describe the event in
detail? What was the child doing before that?
whole body shaking
medication for fever
Have you noticed any LOC? Tongue biting or frothing? head trauma, Passed urine or stools without knowledge? What happened after the episode? (poetical symptoms- sleepy afterwards)
Febrile, Meningitis, Trauma/hemorrhage, Hypo/Hypernatremia.
DIARRHEA
IMIO Infection, Malabsorption, Intussusception, Overfeeding changes in weight change , skin rash, bloody, mucus stools, change color stool, any relationship to meal Infection - Stool mixed with blood and mucus (sometimes referred to as "currant jelly" stool because of its appearance) Malabsorption Intussusception -bloody stool -abdominal pain - predceding abdominal pain OVER FEEDING
COUGH
LPC FERA- productive cyanosais
(sound change on - inhalation or exhalation, always the same ) noisy breathing, is she crying is crying muffled
- For Laryngitis:
a. Have you noticed any change in the voice?- hours voice - For Pertussis:
a. Have you noticed a runny nose or watering from eyes before a cough appeared?
b. Have you noticed any additional sound along with a cough? high pitched whoop
c. Did the baby throw up? after cough - For Croup:
a. Have you noticed any a cough?
b. Have you noticed any sound accompanying? (stridor) - For Foreign Body:
a. What was he doing when a cough started? - For Epiglottitis:
a. Have you noticed any difficulty swallowing?
b. Have you noticed drooling of saliva?
- also has stridor - For Retropharyngeal Abscess: (High-grade fever + No stridor)- muffled voice w drooling
a. Have you noticed any drooling of the saliva? - For Asthma:
a. Does the baby have any allergies?
b. Have you noticed any relationship to the timings of the d
- night time, coughing effect play, abnormal sounds breathing
- peritonsillar abscess- gradual hx sore throat , tonisillits
PICKY EATER
OHIO ATA
OFD Questions
How is the child growing? Did he gain any weight? Milestones achieved?
1. For Organic disorder:
a. Have you noticed any change in bowel habits?
b. Have you noticed any blood in stools?
c. Have you noticed crying discomfort on passing stools?
2. For Habitual Eating Disorder:
a. Do you follow a set schedule of meals?
b. Does he drink a lot of high-calorie drinks?
3. For Iron Deficiency:
a. Have you noticed a change in skin color?
b. Have you noticed a bleeding from any site?
5. For Autism:
a. Does the child have problems playing with others?
6. For HypoThyroidism: (temp intolerance)
a. Have you noticed a change in bowel habits?
chest X ray - lateral and posterior
Xray - neck- AP and lateral
cbc with differential
ABG
diabetes mettilus
type onset presenting symptoms at he time of diagnosis effect on child effect on parent regular screening medication compliance with insulin schedule of insulin meaning glucose at home ranges of blood glucose readings most recent glucose hypoglycemia urination abnormal thirst vision weight changes patient weight an heigh t
behavorial
- For Oppositional Defiant disorder:
a. How is his behavior towards others? - For Autism:
a. Does the child have problems playing with others? - For Adjustment disorder:
a. Have you recently moved?
b. Has the child suffered any trauma recently?
ADHD- TSH, FT4, mental status exam, physical exa
implusive
- hard time waiting to talk or react
hyperactive
fidget or squirm when seated
Inattention
- trouble stay on topic when talking
- lack of focus
Conduct disorder/substance - urine toe physic/mentla
- aggressive towards people/lying/theft/ breaking property
Oppostional defiance disorder
Deliberately refuses to follow rules and annoys others
bed wetting
PUB SSB
intervention tried
effect on child/parent
alley/aggraav
primary nocturnal enuresis
- diagnosis of exclusion- family history
UTI - pain with urine/ color of urine/blooding urin
Bowel - constipation
sleep- apnea - hard time breathing wake up at night
secondary enuresis: any change in environment, any recent stress/trauma
functional bladder disorder - void several times a day hold urine till last minute wet small volumes at night multiple times - time of day of incontinence, volume of urine
diagnosis
urine culture + analysis
Jaundice
- obstruction/atresia- bowel movements per day, colour of stool, bloating( belly larger then usual ), blood in stool
- breast feeding - breast feed or formula, how often does he require feeding - difficulty breastfeeding,- milk production sucking well - breast milk/breast failure jaundice
- blood type - your blood type father blood type
- Infections: any flu or cold, fever, breathing fast dry mouth shaking (seizures), ill contacts
- fh - hx
Late onset > 1 week metabolic disorder, breast milk jaundice, biliary actress ( rare) early <1 week physiologic jaundice ABO or RH neontal jaundice neonatal sepsis - broth cephalohematoma polycthemia FH - hx - familial neontal hyperbilirubinemia tests total and indirect blood typing and direct coombs CBC with differentials serology foro cmv, toxoplasmosis, rubella RPR for syphilis TSH, FT4 hypothyroidism
