History
Personal History :
Name :
Age :
Sex :
Nationality :
Date & Place of birth :
School :
Father's Name & Occupation :
Mother's Name & Occupation :
Origionally from :
Lives in :
Informant & reliability :
Chief Complaint:
ER or OPD Admission
How many days
Shief Complaint :
Duration of CC :
History of Present Illness:
Hx of Chronic Diseases
When Dx
Where ?
what complaint
investigation ?
MGM ?
ER Visit / Month ?
Admissions / year ?
medications ?
complication of ttt ?
complication of Disease ?
Analyse symptoms of this admission
Interval History:
Well Child :
illnesses , TTT
Rx to Immunization
Chronic ill child :
condition since last visit
current medication
frequency of Medication
Family response to illness
Past History:
Prenatal:
antenatal care ?
US ? How frequent ?
Any abnormality was detected ?
Hx of DM
Hx of HTN
Hs of exposure to Radiation
Hx of Bleeding
Natal:
Delivery ?
normal spontaneous vaginal delivery.
Caesarean Section ? Why ?
Neonatal:
Hx of Complication during delivery
Hx of birth asphyxia
Hx of jaundice
Past medical Hx
Hospitalization
Past surgical Hx
Developmental History:
Smile à 3 M
Da Da – Ma Ma à 7 M
Creeps on hand & Knnes à 10 M
Walk à 12 M
Sphincter control by Day time à 18 M
Vaccination:
Took all required Vaccine up to date ?
How # viaccine Missed ?
Special Vaccine ?
Personal History & Habits :
Relation to other Children
School Progress
Eating : appetite , food dislike , how fed
Sleeping : hours , Disturbance , snoring
Exercise & Play
Behavior : bedwetting , thumb sucking , nail biting , tember tantrum
Nutritional History:
Breast or formula
Time of Weaning ? Why ?
Solid food
appetite
Food allergy
Family History:
Father : Age & condition of Health
Mother : Age & condition of Health
Consanguinity
Sibling : # , conditions
Maternal Pregnancy : stillbirths , miscarriage , abortions
family illnesses
Marital relationship
Social History:
where they are living ?
they own the house or rented
how many rooms ?
Socioeconomic state
Father's education , smoking or not
School Hx ?
Systemic Review:
CNS :
nervousness
convulsions
ataxia
weakness
unusual headache
dizziness
head trauma
Eyes :
blurring of vision
Diplopia
Photophobia
Eye pain or itching or Trauma
Use of eye drops or Familial eye diseases.
Ear :
hearing loss
Ear pain or itching
Ear discharge
Tinnitus or vertigo.
Nose :
nasal obstruction or epistaxis
Post nasal discharge
Change of smell sensation
Sinus pain
nasal drip
snoring
Mouth and Throat:
bleeding tendency
swelling of gum
ulcer of tongue
Mouth ulcer
Disturbance of taste
frequent sore throat
Teeth :
age of eruption
# of teeth at one year of age
Teeth fall
Cardiovascular System:
chest pain
Dyspnoea
Orthopnea
PND
Palpitations
Cough or Sputum
Ankle swelling
intermittent claudication
Respiratory System:
cough
sputum or
hemoptysis
Dyspnoea
Chest pain
Night sweat
hoarseness
Gastrointestinal System:
abdominal pain
abdominal distention
vomiting
diarrhea
constipation
jaundice
pruritis
Reticulo-Endothelial System:
lymph node enlargement
tenderness or suppuration
upper abdominal mass.
Genito-Urinary System:
enuresis
dysuria
frequency
polyurea
hematuria
vaginal discharge
abnormalities in penis or testis
Endocrine:
disturbance of growth
excessive fluid intake
polyphagia
goiter
thyroid disease
Musculo-Skeletal System:
joint stiffness
restriction of motion
Joint swelling
postural deformities
Bony deformity
Muscular pain
muscular weakness
Hematological System:
Bruises
tendency to bleed easily
history of thrombosis
Skin :
color
texture
bruises
rash
eruption
itching
pigmentation
abnormal hair or nail growth
Physical Examination
General Appearance:
Look ( ill or well )
Dysmorphic Features
Nutritional State
Color
Vital Signs :
Pulse Rate :
Blood pressure:
Respiratory rate:
Temperature:
Growth parameters:
Weight: 20.5 kg, at the 25thpercentile.
Height: 124 cm, at the 75th percentile.
Head circumference: 58 cm
Heads and Neck :
Eyes :
conjunctiva
sclera
strabismus
Face :
pigment
telangiectasias
salivary gland enlargement.
Ears :
auricle
discharges.
Nose :
obstruction
nasal polyps
sinus tenderness
cleft palate
nostril atresia
Mouth and Oral Cavity :
Oral Hygiene
Buccal Mucosa
ulcers
gum
tongue
Neck :
JVP
Carotid
Trachea
Lymph Nodes
Thyroid
Hand & arm:
Nail :
clubbing
cyanosis
pallor
deformities
Palm :
warm, moisture
Palmer crease
muscle wasting
Dorsum :
Muscle wasting
purpura
telangiectasias.
Lower Limbs:
Posture
Pigmentations
dilated veins
nail change
deformities
joint swelling
ulcers
Pulses
Chest :
Inspection:
symmetricity
chest deformities
Type of breathing
chest wall veins or telangiectasias Apex beat visible on mid-clavicular line and no other visible pulsations.
Palpation :
tenderness
subcutaneous emphysema
Chest expansion
Tactile vocal fremitus
Percussion:
Auscultation:
Air entry
intensity
type of breathing
vesicular
bronchovesicular
bronchial
added sound
wheeze
crepitations
friction rub
Vocal resonance
Heart
Inspection :
chest deformities
precordial bulge
visible pulsation
no scars
Palpation :
Apex beat
parasternal heave
no palpable thrill.
Auscultation:
S
S2
added sounds
murmur
time
Grade
character
best heard
radiation
Maneuver
Abdomen :
Inspection:
symmetricity
umbilicus
scars cattery marks or striae.
skin pigmentation.
dilated veins.
visible pulsation.
visible peristalsis.
Palpation :
Superficial palpation:
tenderness
superficial masses
Deep Palpation:
Deep tenderness
Deep masses
Organ Palpation:
Liver
Spleen
Kidney
Ascitis
Percussion :
Auscultation :
bowel sounds
vascular bruit
venous hum.
friction rub.
Neurological Examination:
General :
interaction
activity
Posture
skin changes
MSE :
response to environment
activity
Cranial nerves:
olfactory
Optic :
visual acuity
visual feiled
papillary reflex
fundoscopy
3rd , 4th , 6th :
5th :
sensory :
motor
reflexes
Facial :
sensory ( ant 2/3 of tongue )
motor :
raise yr brows
close the eyes
show yr teeth
blow
8th :
hearing
weber & Rinne
caloric test
nystagmus
9th & 10th : gag reflex
11th
12th
Upper limb:
Right Left
Tone NL NL
Power 5/5 5/5
Reflex ++ ++
Sensation NL NL
Gait and coordination: the patient gait is normal with Normal coordination.
Negative Signs of meningial irritation :
1\ -ve neck stiffness.
2\ -ve Kernig‘s sign.
3\ -ve Brudziniski sign.
Lower Limb:
Right Left
Tone NL NL
Power Hip flexion 5/5 5/5
Hip extension 5/5 5/5
Hip add. 5/5 5/5
Hip abd. 5/5 5/5
Knees flex. 5/5 5/5
Knees ext. 5/5 5/5
Dorsiflexion 5/5 5/5
Planter flexion 5/5 5/5
Reflex Knees ++ ++
Ankle ++ ++
Planter NL NL
Clonus -ve -ve
Sensation Touch NL NL
Temp. NL NL
Joint Position NL NL
Vibration NL NL
Differential Diagnosis:
1-
2-
3-
Investigations
Management
Personal History :
Name :
Age :
Sex :
Nationality :
Date & Place of birth :
School :
Father's Name & Occupation :
Mother's Name & Occupation :
Origionally from :
Lives in :
Informant & reliability :
Chief Complaint:
ER or OPD Admission
How many days
Shief Complaint :
Duration of CC :
History of Present Illness:
Hx of Chronic Diseases
When Dx
Where ?
what complaint
investigation ?
MGM ?
ER Visit / Month ?
Admissions / year ?
medications ?
complication of ttt ?
complication of Disease ?
Analyse symptoms of this admission
Interval History:
Well Child :
illnesses , TTT
Rx to Immunization
Chronic ill child :
condition since last visit
current medication
frequency of Medication
Family response to illness
Past History:
Prenatal:
antenatal care ?
US ? How frequent ?
Any abnormality was detected ?
Hx of DM
Hx of HTN
Hs of exposure to Radiation
Hx of Bleeding
Natal:
Delivery ?
normal spontaneous vaginal delivery.
Caesarean Section ? Why ?
Neonatal:
Hx of Complication during delivery
Hx of birth asphyxia
Hx of jaundice
Past medical Hx
Hospitalization
Past surgical Hx
Developmental History:
Smile à 3 M
Da Da – Ma Ma à 7 M
Creeps on hand & Knnes à 10 M
Walk à 12 M
Sphincter control by Day time à 18 M
Vaccination:
Took all required Vaccine up to date ?
How # viaccine Missed ?
Special Vaccine ?
Personal History & Habits :
Relation to other Children
School Progress
Eating : appetite , food dislike , how fed
Sleeping : hours , Disturbance , snoring
Exercise & Play
Behavior : bedwetting , thumb sucking , nail biting , tember tantrum
Nutritional History:
Breast or formula
Time of Weaning ? Why ?
Solid food
appetite
Food allergy
Family History:
Father : Age & condition of Health
Mother : Age & condition of Health
Consanguinity
Sibling : # , conditions
Maternal Pregnancy : stillbirths , miscarriage , abortions
family illnesses
Marital relationship
Social History:
where they are living ?
they own the house or rented
how many rooms ?
Socioeconomic state
Father's education , smoking or not
School Hx ?
Systemic Review:
CNS :
nervousness
convulsions
ataxia
weakness
unusual headache
dizziness
head trauma
Eyes :
blurring of vision
Diplopia
Photophobia
Eye pain or itching or Trauma
Use of eye drops or Familial eye diseases.
Ear :
hearing loss
Ear pain or itching
Ear discharge
Tinnitus or vertigo.
Nose :
nasal obstruction or epistaxis
Post nasal discharge
Change of smell sensation
Sinus pain
nasal drip
snoring
Mouth and Throat:
bleeding tendency
swelling of gum
ulcer of tongue
Mouth ulcer
Disturbance of taste
frequent sore throat
Teeth :
age of eruption
# of teeth at one year of age
Teeth fall
Cardiovascular System:
chest pain
Dyspnoea
Orthopnea
PND
Palpitations
Cough or Sputum
Ankle swelling
intermittent claudication
Respiratory System:
cough
sputum or
hemoptysis
Dyspnoea
Chest pain
Night sweat
hoarseness
Gastrointestinal System:
abdominal pain
abdominal distention
vomiting
diarrhea
constipation
jaundice
pruritis
Reticulo-Endothelial System:
lymph node enlargement
tenderness or suppuration
upper abdominal mass.
Genito-Urinary System:
enuresis
dysuria
frequency
polyurea
hematuria
vaginal discharge
abnormalities in penis or testis
Endocrine:
disturbance of growth
excessive fluid intake
polyphagia
goiter
thyroid disease
Musculo-Skeletal System:
joint stiffness
restriction of motion
Joint swelling
postural deformities
Bony deformity
Muscular pain
muscular weakness
Hematological System:
Bruises
tendency to bleed easily
history of thrombosis
Skin :
color
texture
bruises
rash
eruption
itching
pigmentation
abnormal hair or nail growth
Physical Examination
General Appearance:
Look ( ill or well )
Dysmorphic Features
Nutritional State
Color
Vital Signs :
Pulse Rate :
Blood pressure:
Respiratory rate:
Temperature:
Growth parameters:
Weight: 20.5 kg, at the 25thpercentile.
Height: 124 cm, at the 75th percentile.
Head circumference: 58 cm
Heads and Neck :
Eyes :
conjunctiva
sclera
strabismus
Face :
pigment
telangiectasias
salivary gland enlargement.
Ears :
auricle
discharges.
Nose :
obstruction
nasal polyps
sinus tenderness
cleft palate
nostril atresia
Mouth and Oral Cavity :
Oral Hygiene
Buccal Mucosa
ulcers
gum
tongue
Neck :
JVP
Carotid
Trachea
Lymph Nodes
Thyroid
Hand & arm:
Nail :
clubbing
cyanosis
pallor
deformities
Palm :
warm, moisture
Palmer crease
muscle wasting
Dorsum :
Muscle wasting
purpura
telangiectasias.
Lower Limbs:
Posture
Pigmentations
dilated veins
nail change
deformities
joint swelling
ulcers
Pulses
Chest :
Inspection:
symmetricity
chest deformities
Type of breathing
chest wall veins or telangiectasias Apex beat visible on mid-clavicular line and no other visible pulsations.
Palpation :
tenderness
subcutaneous emphysema
Chest expansion
Tactile vocal fremitus
Percussion:
Auscultation:
Air entry
intensity
type of breathing
vesicular
bronchovesicular
bronchial
added sound
wheeze
crepitations
friction rub
Vocal resonance
Heart
Inspection :
chest deformities
precordial bulge
visible pulsation
no scars
Palpation :
Apex beat
parasternal heave
no palpable thrill.
Auscultation:
S
S2
added sounds
murmur
time
Grade
character
best heard
radiation
Maneuver
Abdomen :
Inspection:
symmetricity
umbilicus
scars cattery marks or striae.
skin pigmentation.
dilated veins.
visible pulsation.
visible peristalsis.
Palpation :
Superficial palpation:
tenderness
superficial masses
Deep Palpation:
Deep tenderness
Deep masses
Organ Palpation:
Liver
Spleen
Kidney
Ascitis
Percussion :
Auscultation :
bowel sounds
vascular bruit
venous hum.
friction rub.
Neurological Examination:
General :
interaction
activity
Posture
skin changes
MSE :
response to environment
activity
Cranial nerves:
olfactory
Optic :
visual acuity
visual feiled
papillary reflex
fundoscopy
3rd , 4th , 6th :
5th :
sensory :
motor
reflexes
Facial :
sensory ( ant 2/3 of tongue )
motor :
raise yr brows
close the eyes
show yr teeth
blow
8th :
hearing
weber & Rinne
caloric test
nystagmus
9th & 10th : gag reflex
11th
12th
Upper limb:
Right Left
Tone NL NL
Power 5/5 5/5
Reflex ++ ++
Sensation NL NL
Gait and coordination: the patient gait is normal with Normal coordination.
Negative Signs of meningial irritation :
1\ -ve neck stiffness.
2\ -ve Kernig‘s sign.
3\ -ve Brudziniski sign.
Lower Limb:
Right Left
Tone NL NL
Power Hip flexion 5/5 5/5
Hip extension 5/5 5/5
Hip add. 5/5 5/5
Hip abd. 5/5 5/5
Knees flex. 5/5 5/5
Knees ext. 5/5 5/5
Dorsiflexion 5/5 5/5
Planter flexion 5/5 5/5
Reflex Knees ++ ++
Ankle ++ ++
Planter NL NL
Clonus -ve -ve
Sensation Touch NL NL
Temp. NL NL
Joint Position NL NL
Vibration NL NL
Differential Diagnosis:
1-
2-
3-
Investigations
Management
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