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PROFESSOR IFEOMA EMODI DEPARTMENT OF PAEDIATRICS
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Introduction BiodataPresenting complaints History of presenting complaints Past medical historyObstetric history Immunisation Milestones Family and social history Drug history Review of systems Physical examination
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In the next few minutes we are going to go through history taking and examination in paediatrics This will be added upon while doing your rotation in the wards and clinics Relatively easy but you need to practice The mother is very important in this process A lot of information may be obtained watching the child while taking the history
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Greet and introduce yourself Name Sex Age Informant Religion Domicile/Address Place of Origin ? Referral
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What brought you to hospital? How long is the symptom? Chronological order
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Expand on PC-each symptom Treatment given Hospitals attended Improvement / deterioration
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Prior admissions Blood transfusions Surgery Frequent illnesses Prior diagnosis Regular hospital visits
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Normal aspects of children life and development with need to ask WHY There was deviation from the usual
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Ante natal care Delivery Neonatal period
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Breast feeding ◦ Exclusive or not Weaning age,what type of food Family diet ◦ When and what ◦ Who feeds the child 24 hr meal recall If child is malnourished
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National program of Immunisation Obtained/ missed
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Head control/ social smile Sitting with/without support Crawling Standing Walking Pincer grip menarche
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Number in family Mother/father Other siblings Domicile Facilities Similar illness Inherited disease Death in family
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Regular medication Drug reactions if any
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Hematologic Digestive Respiratory Cardiovascular Renal Endocrine Neurologic musculoskelatal
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Joint pain/swelling Bone pains Abnormal gait paralysis
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Pallor Easy fatiguability Purpura Epistaxis Yellow eyes Leg ulcers Angular stomatitis
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Weakness Oedema Palpitation Cough Chest pain Fast breathing Dyspnoea on exertion Orthopnea Paroxysmal nocturnal dyspnoea
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Catarrh Cough Sore throat Noisy breathing Haemoptysis Fast breathing Sneezing
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Excessive weight gain / loss Coarse voicePolyuria AmenorrhoeaTetany Cold/heat intoleranceIncreased appetite HirsutismNeck swelling Polyphagia polydypsia
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PolyuriaHaematuria DysuriaUrgency Loin painOedema Urgency of micturition Frequency of micturition Abnormal urinary stream
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Abdominal pain /swelling NauseaVomiting DiarrhoeaConstipation Weight lossAnorexia DysphagiaTenesmus Yellow eyes Loss of appetite
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HeadacheDizziness IrritabilitySeizure Loss of consciousnessDiplopia ParesisParasthesia NauseaVomiting Neck stiffnessFainting AphasiaEchopraxia SomnolenceTremor
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‘If a child cries when you examine him/her it is your fault’ Gain their confidence Older child – adolescent Younger child – on mums lap Always talk to the child no matter the age
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General examination Systemic examination
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General examination ◦ Introduce patient ◦ Pallor, jaundice, clubbing, dehydration ◦ Temperature, oedema, cyanosis ◦ Anthropometry – weight, height/length Mid Upper Arm Circumference, head circumference with comments ◦ Vital signs
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Massive cervical lymphadenopathy HIV Encephalopathy National Paediatric ART Training Slides Unit 3 20 Clinical Features and Associated Conditions …cont…
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Severe wasting National Paediatric ART Training Slides Unit 3 16 Clinical Features
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Always start with the system you feel has the problem or diagnosis Inspection Palpation Percussion Auscultation Thank the patient and/or care give
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Any questions Thank you
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