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Year
3 medical students King Fahad Medical City on December 25, 2014 by Professor
Omar Hasan Kasule Sr.
1.0 DEMOGRAPHIC
INFO
·
Names of child and parent(s)
·
Age and date of birth
·
Residential address
·
Parental occupation
·
Child’s school etc
2.0 HISTORY
OF PRESENTING COMPLAINT
·
Onset, course, location, severity, time of day,
duration, diurnal variation, character, aggravating factors (food, cough etc ),
relieving factors
·
Associated symptoms,
·
What does the parent think is going on?
·
Treatments already given
·
How the family is affected
·
Missing school
·
Associated behavioral problems
3.0 PAST
MEDICAL / SURGICAL HISTORY
·
Prenatal period: prenatal care for the mother
(where and how much); alcohol, drugs, and
cigarettes by the mother;
·
Birth: mode of delivery (Cesarean or vaginal),
delivery complications, APGAR score
·
Neonatal period: respiratory problems, feeding
problems, jaundice
·
Chronic illnesses: asthma, respiratory
infections
·
Childhood infections; eg measles varicella
·
Hospitalizations
·
Surgeries
4.0 NUTRITIONAL
HISTORY
·
Breast feeding (how often, baby satisfied?,
crying, urine output), time of weaning
·
Formula: brand name, how prepared, how stored,
·
Solid food: types and amounts, ?junk food
·
Milk and juices
5.0 DEVELOPMENTAL
HISTORY
·
Gross motor & Fine motor
·
Vision
·
Social and play
·
Speech and hearing
6.0 ALLERGY
HISTORY
·
Reactions to medications: type and drug
·
Distinguish true allergy vs medication effects
(eg vomiting)
·
Food allergies
·
Environmental allergies
7.0 MEDICATION
HISTORY
·
List of current medications doses and why
·
List of chronic medications
8.0 IMMUNIZATION
HISTORY
·
Record of the whole immunization schedule
·
Reactions to immunization: swelling, tenderness,
fever
·
Treatment of reaction
9.0 FAMILY
HISTORY
·
Parents: age, height, weight, health status,
consanguinity, region of origin
·
Siblings: names, nicknames, age, height, weight,
health status
·
Significant problems maternal & paternal sides: arthritis, DM,
HT, renal disease, anemia, headache, TB
10.0 SOCIAL
HISTORY
·
Type of housing, location (city vs rural), how
many people in house
·
Parents: education, occupation, income, religion
and culture, smoking
·
Care for children: baby sitter, grandparents,
other relatives,
·
Discipline (may relate to child abuse)
·
Health insurance
·
Contact with animals
11.0 REVIEW
OF SYSTEMS (If not covered in presenting complaints and PMH)
·
Skin: skin rash,
·
CVS: dypnea, cyanosis, sweating on feeding
·
Hematological: pallor, jaundice, bone pain,
bruises, epistaxis
·
RES: dypnea, runny nose, cough, hemoptysis,
wheeze/stridor, sore throat, ear ache,
·
GIT: Vomiting, abd pain, diarhoea /
constipation, Bowel habits, feeding, weight loss
·
Urinary tract: dysuria, enuresis, frequency.
Nocturia, hematuria, incontinence
·
CNS: irritability, drowsiness, abnormal movements,
headache, numbness,
·
Sleeping: night walking, crying, sleep walking,
sleep talking, nightmares,
·
Musculoskeletal: joint swelling, joint pain,
skin rash
·
Behavior: temper tantrums, sibling rivalry,
mealtime behavior, bedtime behavior,
12.0 Risk
factors - Pyrexia of undetermined origin (PUO)
·
Infections (bacterial, viral, parasitic)
·
Drug reactions
·
Allergy
·
Dehydration
·
Neoplasms
·
Factitious
13.0 Risk
factors - Failure to thrive (height for age. Weight for age, weight for height,
birth weight, milestones)
·
Familial
·
Delayed but normal growth
·
Inadequate caloric intake (no food, poor
appetite, wrong food, psychosocial eg maternal depression, family disruption)
·
Renal disease (infection, renal failure)
·
Cardiovascular:
congenital heart disease, endocarditis, myocarditis
·
GIT: cleft lip / palate. Esophageal compression,
gastro-intestinal reflux, hernia, pyloric stenosis, celiac disease,
hepato-pancreatic disorders, endocrine disorders (thyroid, GH deficiency,
adrenal insufficiency, diabetes)
·
Musculoskeletal: rickets due to Vit D
deficiency,
·
Chronic infections: TB,
·
Metabolic disorders (
·
Chronic anemia:
thalassemia, sickle cell disease,
·
Respiratory: Chronic lung disease: asthma,
infections, airway obstruction
14.0 Risk
factors - Weight loss
·
Infections
·
Eating disorders
·
Depression
·
Thyrotoxicosis
·
Renal failure
·
Malignancy
·
Inflammatory bowel disease
·
Celiac disease
15.0 Risk
factors - Pallor
·
Anemia
·
Infection
·
Allergic reaction
·
Hereditary
·
Lack of sun exposure
·
Atopy
16.0 Risk
factors - Jaundice
·
Hemolytic disorders
·
Physiological jaundice of the new born
·
Infection: sepsis, hepatitis
·
Biliary tract disorders
17.0 Risk
factors - Earache
·
Acute otitis media
·
Otitis externa
·
TMJ dysfunction
·
Acute pharyngitis
·
Ear trauma
18.0 Risk
factors - Nasal obstruction
·
Recurrent URTI
·
Adenoid hypertrophy
·
Foreign body
·
Allergic rhinitis
·
Sinusitis
·
Nasal septal deviation
19.0 Risk
factors - Epistaxis
·
Trauma: digital or external
·
Allergic rhinitis
·
Exercise
·
Low humidity /dry air
·
URTI
·
Bleeding disorders
20.0 Risk
factors - Chest pain
·
Trauma
·
Psychogenic
·
Costochondritis
·
Esophagitis
·
Asthma
·
Cough
·
Pneumonia
·
Sickle cell disease
21.0 Risk
factors - Cough
·
Infections
·
Asthma
·
Gastroesophageal reflux
·
Allergies from the environment
·
Allergic rhinitis / post nasal drip
·
Sinusitis
·
Foreign body
22.0 Risk
factors - Abdominal pain
·
Constipation
·
Malabsorption
·
Gastoenteritis / enterocolitis
·
Appemdicitis
·
Too much dietary intake
·
Trauma
23.0
Risk factors - Diarrhea
·
Infections: viral, bacterial, parasitic
·
Overfeeding
·
Malabsorption
·
Food allergies
·
Inflammatory bowel disease
24.0 Risk factors - Vomiting
·
Projectile vomiting: pyloric stenosis, hiatal
hernia, peptic ulcer, duodenal obstruction
·
Infection
·
CNS (pressure): intracranial hemorrhage, brain
tumors, hydrocephalus
·
Metabolic disorders
25.0 Risk factors - Hematuria
·
Cystitis
·
Urethritis
·
Meatal ulceration
·
Urolithiasis
·
Trauma
·
Drugs
·
Coagulopathy
·
Exercise
·
Sickle cell disease
·
Nephropathy
26.0 Risk factors - Seizures
·
Febrile
·
Idiopathic epilepsy
·
Head trauma
·
Hypoxic-ischemic encephalopathy
·
Intracranial hemorrhage
·
CNS infection
·
Drug / toxins