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
