Pediatrics Full History Taking & Examination

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Pediatrics Full History Taking & Examination With Mnemonics that help you Remember all parts of the History & Exam

Based on Pediatric Department History Taking Guide Faculty of Medicine – University of Aden Prepared by Hussein Kolaise Abobakr Al Hamed 2019

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Special Thanks to Dr. Fatima AL-Musawa Pediatric Lecturer in the Pediatrics Department Faculty of Medicine & Health Sciences University of Aden for her valuable contribution to this work.

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Personal Data

Remember NASR DOI

1. Name 2. Age 3. Sex 4. Residency (Permanent/Temporary) 5. Date of Admission and Time (duration of admission) 6. Order of Birth 7. Informant

Chief Complaint 1. 2. 3.

History of Present Illness Arrange them in chronological manner and mention the important (+ —) findings in the involved systems . (if patient has documented congenital disorder mention when discovered, if patient has chronic disease mention when started)

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Review by System

Check out all other systems .

NB: In review by systems 1.Complaints should be described in words related to the age of patients, e.g; headache in infancy will be manifested as irritability or excessive crying. 2. Try to focus on complaints that help you in diagnosis. Do not mention irrelevant symptoms.

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Past History 1. Any Previous similar conditions 2. Any Previous Hospitalization 3. Any Diseases 4. Any Blood Transfusions (Frequency and Last one) 5. Any injuries 6. Any Surgery 7. Any Drugs taken.

Birth History  Antenatal

Remember MBH DVD RS

1. Mother Age 2. Blood Group 3. Health condition 4. Diseases or Infection. 5. Vaccination & Visits to Antenatal Care. 6. Drugs. 7. Radiation Exposure. 8. Smoking.

 Natal

Remember RBC G LIPD

1. Resuscitation Done & Why?

6. Injury?

2. Birth Weight?

7. Presentation (Cephalic or Breech), any PROM?

3. Cried When?

8. Delivery Info (Mode, Route and Place of Delivery).

4. Gestational Age? 5. Labor Duration? Hussein et al, 2019

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 Postnatal

Remember JAC ADUMS

1. Jaundice 2. APGAR Done? 3. Cyanosis. 4. Abnormal movements. 5. Difficulty of Breathing 6. Urine Passing when? 7. Meconium Passing when? 8. Sucking and Activity. ✓ Developmental History  Infant

Remember SC – HT – SC - SWM

1. Smiled (2month). 2. Cooing (2month). 3. Head holding (3month). 4. Turning over (5month). 5. Sitting supported (6month), unsupported (7month). 6. Crawling (8month). 7. Stands supported (10month), unsupported (11month). 8. Walk supported (12month). 9. Mama, Dada (12month)

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❖ Toddler (2 – 4 years) 1. Going up stair (with or without Support). 2. Using cup 3. Talking meaningful words 4. Bowel bladder control ❖ Older child

Remember the 3 S

1. School performance/Class 2. Social activity 3. Sexual development. How is his Learning Ability? Teething? Feeding/ Nutritional History  Infant

Remember Breast

PTSD

Bottle

TFC PVF

1. Breast or Bottle feeding 2. If Breast (Problems, Times per day, Satisfactory, Duration) 3. If Bottle (Type, Formula, Cow or goat, Preparation, Volume, Formula) 4. How is preparation (volume, frequency) 5. Bottle why? 6. When was weaning (how and with what Started). 7. Any supplements (Vitamins, Iron) & why? 8. Any exposure to Sun?

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 Children  No of feeds/day?  Contents of meals (Balanced or not?)?  Any supplements?  How is the appetite?

Vaccination History

Remember the 4 Ws and its Complications.

1. What was received? 2. When (Dates)? 3. Where (The Routes)? 4. Why not Complete or not received? 5. Complications (fever, rash etc.). 6. Look for Documents/BCG scar

Family History

Remember FM CHEIS

1. Father and Mother Age? 2. Consanguinity? 3. History of similar conditions 4. Illnesses? 5. Siblings (Number, sex, similar problem, any illnesses or death & why?) Hussein et al, 2019

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Draw a family Pedigree (Important)

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Social History

Remember JAWESH

1. Job of Parents 2. Animals at home? 3. Water supply & Electricity. 4. Education 5. Sewage system ( Sanitary Conditions) 6. House (number of rooms, number of members in the same room, ventilation and light).

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Physical Examination General

General

Regional

Systemic

Remember AHN – DVA

1. Appearance. 2. Hydration Status. 3. Nutritional Status. 4. Dysmorphic Features 5. Vital signs 6. Anthropometric Measurements. ✓ Appearance (Make note on each) - CONSCIOUS - LOOKS (mildly ill, ill, Severely ill) - ORIENTED (Place, Time & Person) (if 5 years) 2. Malnourished (mild/mod/severe) with wt/ht z score……,MUAC……(for patients6 months- 5 years)

Regional Exam (Head to Toe Exam) Remember HEENT – Chest - Abdomen ✓ Head: Skull: Shape, Prominence, State of Anterior Fontanel etc. Scalp: Hair (Color, Distribution, texture, Sparseness etc.) ✓ Ears: Shape, Size and signs of infection etc. ✓ Eyes: Abnormalities, Signs of infection or inflammation etc. ✓ Neck: Short, Webbed, Sternomastoid swelling, Thyroid Swelling Lymph node enlargement etc.

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✓ Throat & Mouth: Teeth (Number and condition) Gum (Ulcer, Hypertrophy, Tongue (Thrush, Coating) Tonsils (Size, Congestion, Exudates), Palate (Anomalies, Enanthem) Pharynx (Redness, Congestion). ✓ Chest: Deformities, Scar, Retractions, Pulsation, Abnormalities of Breast, Rosary beads.

✓ Abdomen Disrension, Shape, Tenderness, Organomegaly, Masses.

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Some of the Physical Examination Finding Notes Taken from PEDIATRIC PHYSICAL EXAMINATION: AN ILLUSTRATED HANDBOOK, SECOND EDITION

KAREN G. DUDERSTADT, PHD, RN, CPNP, PCNS

✓ Cardiovascular system

✓ Respiratory System

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✓ Abdomen

❖ Systemic Examination Follows a systematic approach Inspection, Palpation, Percussion and Auscultation. Please refer to the Pediatrics Department Guide on Systemic examination. ❖ NB; Start with the involved system.

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