PEDIATRIC SHEETS

PEDIATRIC SHEETS

  General pediatric sheet

HISTORY TAKING

Wilcome the pt

Introduce yourself to pt,explain whate going to do

1-PERSONAL HISTORY

1-sex and name

2-age

3-residance

4-consangunity

2-complaint

-In parents

or child s ownwards

-No leading questions

-No medical terminology e.g you can say swelling of lower limb but not edema

-Should be arranged chronologically

3-pres ent history

1-Analysis of the complaint

onset

*Sudden(withen second or minutes)

*Rapid (within hours)

*Gradual(within days or weeks)

-Course

Progressive

Regrseeive (spontaneausly or with therapy)

Stationary

Intermittent(periods free from disease completely)e.g nephrotic syndrom

*remittent :the is partially controlled

·      -duration of the symptoms

·      How long have they been present

NB to remmember the items     look at this,eg pain

SOCRATES:

• Site: where, local/ diffuse, "Show me where it is worst".
• Onset: rapid/ gradual, pattern, worse/ better,.
• Character: vertigo/ lightheaded, pain: sharp/ dull/ stab/ burn/ cramp/ crushing.
• Radiation [usually just if pain].
• Alleviating factors, "
• Time course: when last felt well, chronic: why came now.
• Exacerbating factors, " Severity:.
• Associated symptoms.
• Impact of symptoms on life: "Does it interrupt your life".

·      2-Also ask abut

·      Who  else  is  sick?  (family members, daycare contacts)

·       

·      Has this patient ever had a similar illness?

·       

·      What  treatments  have been tried for this problem?and what

·       

·      investigation done?

·       

·      and past medical history.

·       

3-Ask about symptoms of other system affected

-chest:cough if with expectoration or heamoptysis,cyanosis,recurrant chest infection

-cardiac:dyspnea,difficulty of breathing,difficulty with feedig,cyanosis and what increase it, palptation

-GIT:vomting,diarrhea,constipation,jundce

-UTI:dysurea or crying with urination,heamaturea,oedema

-NEURO:convulsion or abnormal movment

-fever

4- past history

a-prenatal&perinatal history

-antinatal:history of maternal diabetus ,hypertention

History of maternal fever,,skin rash

History of any medication or investigation durig pregnancy

-natal history:if prematur labour or full term

                    Normal labour or c.s

                    Prolonged or difficult labour

                    If cry immediately after 1^st breath or need resussetaion

-neanatal history if the baby has jundce,pallor cyanosis

                    Convulsion,difficulty of breathing

b-devolomental history   motor and mental

a. First raised head, rolled over, sat alone, pulled up, walked with help, walked alone, talked (meaningful words; sentences),.

b. Urinary continence during night; during day.

c.  Control of feces.

d.  Comparison of development with that of siblings and parents.

e.  School grade, quality of work.

f-vision and hearing

c-nutrational history

1. Breast or Formula:  Type, duration, major formula changes, time of weaning, difficulties.  Be specific about how much milk or formula the baby receives.

2. Vitamin ,and mineral Supplements:  Type, when started, amount, duration.

3.  "Solid" Foods:  When introduced, how taken, types.

4.  Appetite:  Food likes idiosyncrasies or allergies, reaction of child to eating.  An idea of child's usual daily intake is important

5-older children - good appetite or "picky eater", special

          diets, milk intake, "", concerns about weight

d-vaccination history

I.  Immunizations and reactions Don't rely on memory; ask to see shot record.

Birth	hepatitis Bl
2 mo	hepatitis B2	DTP1	Hibl	OPV1
4 mo		DTP2	Hib2	OPV2
6 mo	hepatitis B3	DTP 3	Hib3
15 mo			Hib4		MMR1
18 mo		DTP4		OPV3
4-6 yr		DTPS		OPV4	MMR2*
14-16 yr		dT			or MMR2

e- history of.  Previous hospitalizations

age, length of stay, reason,

-  Childhood illnesses or exposures age, complications, treatment recent exposures, date, nature of exposure travel to other locations, animal exposure  allergy,bilharisais,T.B

-  Previous surgery/ transfusions age, reason for procedure, complications

-  Trauma/ injuries/ ingestions, burns age, , treatment, complications,previous operation

f-history of other system affection:see befor

NB-TO  REMMEMBER  ITEMES  OF PAST HISTORY  LOOK AT THIS

·   MJ THREADS:

MI  in older

Jaundice

TB

HTN ["Anyone told you, you have high BP?"]

Rheumatic fever

Epilepsy

Asthma

Diabetes

Stroke

·  Problems with the anesthetic in surgery.

5-family history

A.  Father and mother (age and condition of health).   consangunity

B. Marital relationships.

C. Siblings.  Age, condition of health, significant previous illnesses and problems.

D. Stillbirths, miscarriages, abortions; age at death and cause of death of immediate members of family.

E. Tuberculosis, allergy, blood dyscrasias, mental or nervous diseases, diabetes, cardiovascular diseases, kidney disease, rheumatic fever, neoplastic diseases, congenital abnormalities, cancer, convulsive disorders, others.

F. Health of contacts.

6-  Social History

ONE OF THE MOST IMPORTANT COMPONENTS OF THE HISTORY1

Observe interactions between the family and child.

Reference Algranati, PS.  The Pediatric Patient:  An Approach to history and Physical Examination

N.B   SYSTEMIC REVIEW

A. Skin:  Ask about rashes, , problems with hair, skin texture or color, etc.

B. Eyes Any foreign body or infection, glasses for any reason.

C. Ears, Nose and Throat:  Frequent colds, sore throat, sneezing, snuffy nose, discharge, post-nasal drip, mouth breathing, snoring, otitis, hearing, adenitis.

D. Teeth:  Age of eruption of deciduous and permanent; number at one year; comparison with siblings.

E. Cardiorespiratory:  Frequency and nature of disturbances.  Dyspnea, chest pain, cough, sputum, wheeze, expectoration, cyanosis, edema, syncope, tachycardia.

F. Gastrointestinal:  Vomiting, diarrhea, constipation, type of stools, abdominal pain or discomfort, jaundice.

G. Genitourinary:  Enuresis, dysuria, frequency, polyuria, pyuria, hematuria, character of stream, vaginal discharge, menstrual history, bladder control, abnormalities of penis or testes.

         

H. Neuromuscular:  Headache, nervousness, dizziness, convulsions, habit spasms, ataxia, muscle or joint pains, postural deformities, exercise tolerance, gait.

I. Endocrine:  Disturbances of growth, excessive fluid intake, polyphagia, goiter, thyroid disease.

J. Special senses.

K. General:  Unusual weight gain or loss, fatigue, temperature sensitivity, mentality.  Pattern of growth (record previous heights and weights on appropriate graphs).  Time and pattern of pubescence.

Tanner Stages

Male scoring

1.  Same as in childhood.

2.  Enlargement of testes, scrotum.

3.  Penis lengthened.

4.  Scrotum darkened, penis width increases, glans develops

5.  Pubic hair spreads to medial aspect of thighs.

Female scoring

1.  Same as in childhood.

2.  Breast buds visible.

3.  Enlargement of breast, areola.

4.  Areola rises above rest of breast.

5.  Areola no longer projects from breast.

NORMAL NEWBORN: HISTORY AND PHYSICAL EXAM OUTLINE

Infant:

Birth weight, gestational age, intrauterine growth (AGA, SGA, LGA), race, sex, date and time of birth.

Maternal:  

Age; Gravida     , Para                , SAB     , TAB     , SB       ,    ; blood type, race,  Previous complications of pregnancy, labor, delivery.  Type of contraception used, if any.  Was present pregnancy planned?is this the 1^st baby?if not number amange his sibling

Pregnancy:

Location of prenatal care and number of visits.  Complications of pregnancy: Special test, ultrasound exams,. Medications - drug, dose, route, length of therapy, indication, when used during pregnancy.

Labor and Delivery:

• Labor spontaneous or induced?
• Complications of labor
• Fetal monitoring?  Fetal distress?
• Rupture of membranes: artificial or spontaneous, hours before delivery, character of fluid.
• Medications - including analgesia and anesthesia: drug, dose, route, time prior to delivery
• Duration - Stage I, Stage II, Stage III
• Vaginal - or C-section delivery
• Fetal presentation and position
• Forceps used?  If so, state type and indication
• Apgars 1 min/5 min (Specify points lost at each)
• Resuscitation: none; bulb suction; free flowing oxygen; bag and m
  
  
  ask; intubation, drugs used (dose and route)

Transitional Nursery:

• on admission (including BP and temperature)
• Hematocrit
• Dextrostic
• Problems: cyanosis, respiratory distress, etc.
• Estimate of gestational age by Dubowitz - physical score, neuromuscular score

Family:consanguinity and if its degree

Relationship of neonate's mother and father (married, divorced,

Mother: amount of education, and is she employed outside of the home?

Father: age, amount of education, occupation

Any illnesses or other problems in household members?

Any significant illnesses (physical, mental, growth failure) in other members of father's or mother's family?  If so, what?

Is there any disorder(s) in particular that mother worries her child might develop?

Environment:

• Number of bedrooms; running water, bath; explain problems.
• Is adequate heating or cooling a problem?  If yes, explain.
• Do any of the children sleep in the same bed or same room as their parents?

Mother-Child Relationship:

Mother's affect; attitude toward the child; knowledge of child care.

PHYSICAL EXAMINATION

Vital Signs:  T ___    C     Weight ___     gm (=Intrauterine Growth Curve)

P ___  Length ___cm (Intrauterine Growth Curve)

R ___  Head Circumference ___cm (%  "            "       "  )

BP ___ Chest Circumference ___cm (% "            "       "  )

General: Describe resting posture, activity, gross abnormality, color (pink, cyanotic/acrocyanotic, pale mottled),,dysmorphic feature

Skin: Texture, lanugo, vernix, meconium staining, icterus, hemangioma, nevi, rash, excoriation, petechiae, bruises.

Head: General shape, molding, caput, cephalohematome, sutures (over-riding, separated), craniotabes.  Fontanel - anterior, posterior (presence, size, flat/full).  Texture of hair.

Eyes: Edema, conjunctival or anterior chamber hemorrhage, discharge.  Size of eye; cornea, iris normal?  Lens clear?  Red reflex present?  Retina visualized?  PERL?

Nose: Internal and external nares patent?  Septum midline?  Drainage present?

Ears: Cartilaginous development of the ear lobe, position of ears, shape of auricle (normal/abnormal), preauricular sinus or skin tags.  External auditory canal patent.

Mouth: Palate (intact, narrow or high arched), Epstein's pearls, mucosal cysts, teeth, tongue (size, position), frenulum, uvula.

Chin: Micrognathia.

Neck: Trachea position.  Masses (thyroid, sternocleidomastoid, etc.), cysts, sinus tracts, movement, nodes.

Chest: Symmetry.  Breast buds (measure diameter in mm).  Clavicles intact?  Supernumerary nipples?  Axillary adenopathy.

Lungs: Retractions, flaring, grunting, tachypnea, auscultation (rales, rhonchi, wheezes)

CVS: rhythm, rate (tachycardia, bradycardia)

S1, S2 (amplitude equal?  S2 split?)

Murmur (quality, intensity, duration, relation to cardiac cycle, radiation, location of maximum intensity)

Peripheral pulses - femoral, brachial, radial (amplitude, equality, simultaneous)

Peripheral perfusion (capillary filling time)

Abdomen: Shape, muscle tone, number of umbilical vessels, hernia/diastasis.  If palpable, note size and consistency of liver, spleen, kidney, or other masses.  Inguinal adenopathy?

Genitourinary:  

Female- size of clitoris and labia, masses in labia, hymenal tags, discharges, abnormalities in voiding.

Male - urethral meatus patency and position, chordee, testicular descent and scrotal development (i.e., rugae only on inferior aspect, or surface completely covered with rugae and pendulous in appearance).  Hernia or hydrocele, abnormalities in voiding.

Anus: Patency, abnormal stooling.

Extremities: Symmetry, abduction of hips, position of hands and feet.

Number, shape, length of digits, length of nails, Palmar creases normal?  Subcutaneous tissue normal?

Spine: Sinus tracts, sacral dimple, scolioses

Neurologic:

Tone:  active

Head lag; leg and trunk straightening passive

Cry: character, intensity, frequency

Behavior: alertness, wakefulness, irritability,

Reflexes:

       Suck         Grasp (palmer/plantar)           Pacing          

       Root          Tonic neck           Stepping         

       Moro          

Neonatal reflexes

Deep tendon reflex(DTRs)

DTRs (knee, angle, plantar, triceps, biceps) draw figure

Tremor, clonus present?

Paralysis: facial brachial

Estimated Gestational Age:                                 

___ Dubowitz    __   _ Obstetrical Prenatal Assessment

      

An examination called the Dubowitz/Ballard Examination for Gestational Age often is used. A baby's gestational age often can be closely estimated using this examination. The Dubowitz/Ballard Examination evaluates a baby's appearance, skin texture, motor function and reflexes. The physical maturity part of the examination is done in the first two hours of birth. The neuromuscular maturity examination is completed within 24 hours after delivery.

      

How is physical maturity assessed?

       The physical assessment part of the Dubowitz/Ballard Examination examines physical characteristics that look different at various stages of a baby's gestational maturity. Babies who are physically mature usually have higher scores than premature babies.

Points are given for each area of assessment, with a low of -1 or -2 for extreme immaturity to as high as 4 or 5 for postmaturity. The following physical characteristics are assessed:

      

    Skin - ranges from sticky and red to smooth to cracking or peeling.

    Lanugo (the soft downy hair on a baby's body) is absent in immature babies, then appears with maturity, and then disappears again with postmaturity.

    Plantar creases - these creases on the soles of the feet range from absent to covering the entire foot depending on the maturity.

    Breast - the thickness and size of breast tissue and areola (the darkened ring around each nipple) are assessed.

    Eyes and ears - eyes fused or open and amount of cartilage and stiffness of the ear tissue.

    Genitals, male - presence of testes and appearance of scrotum, from smooth to wrinkled.

    Genitals, female - appearance and size of the clitoris and the labia.

      

How is neuromuscular maturity assessed?

       Six evaluations of the baby's neuromuscular system are performed. These include:

      

    Posture - How does the baby hold his/her arms and legs?

    Square window - How much can the baby's hands be flexed toward the wrist?

 Square window

    Arm recoil - How much do the baby's arms "spring back" to a flexed position?

 Arm recoil

    Popliteal angle - How far do the baby's knees extend?

 Popliteal angle

    Scarf sign - How far can the elbows be moved across the baby's chest?

 Scarf sign

    Heel to ear - How close can the baby's feet be moved  
to the ear?

       This baby’s tone is low enough that the heel can almost be drawn up to the level of the ear. The heel in a normal baby would only come to mid chest.

A score is assigned to each assessment area. Typically, the more neurologically mature the baby, the higher the score.

When the physical assessment score and the neuromuscular score are added together, the gestational age can be estimated. Scores range from very low for immature babies (less than 26 to 28 weeks) to very high scores for mature and postmature babies.

   

Reference The University of Arizona Department of Pediatrics