PEDIATRICS 1

MERUGU SHILPITHA
SEC B
STUDENT ID: 15-2-31689

CASE 1: 5 days old, female with yellow eyes of 2days.

GENERAL INFORMATION: Patient name, age, gender, address, religion,

ethnicity, reliability and its percentage.

CHIEF COMPLAINT: What is the purpose of your visit?

HISTORY OF PRESENT ILLNESS:

• When did the yellowing of the eye start?
• What is the course of eye colour change [progressive, intermittent or
fluctuating] ?
• Did you observe the progression of color change in other parts of the body ?
• Is the patient breast fed or formula ?
• How much and how frequent is the baby fed?
• What is the birth weight and the current weight of the patient?
• Number of wet diapers per day?
• what is the color of the urine?
• colour and consistency of stool?
• Any recent infections or fever?
• Any medications [newborn or mother] ?
• General activity: is the patient lethargic ? irritable ?
• Was there any consults done ? if yes, who did you consult? what was the
diagnosis? what was management?

PAST MEDICAL HISTORY:

• Any major illnesses?

• Major surgical illness, operations and dates?
• Previous hospital admission with dates and diagnosis?
• Any current medications?
• Any known allergies?
• Was the patient vaccinated (bcG, HepB vaccines at birth)?

PREGNANCY AND BIRTH HISTORY:

• Was there any maternal illness suggestive of viral or other?

• Was there any maternal medications, drug intake, alcohol or smoking?
• Any delayed cord clamping?
• Any birth trauma, bruising or fractures?
• What was the gestational age of the patient at delivery?
• what was the length of the labor?
• what is the type of delivery [vaginal or cesarean section]? if cesarean section,
why?
• what was the APGAR score?
• was there any need for intensive care? if yes, why?
• was there any hyperbilirubinaemia at birth? if yes, what was the
management?
• were there any feeding problems? if yes, why?
• what was the length of stay at hospital after birth?
• what was the birth weight of the patient?
• What is the maternal blood group?
• What were the results of new born screening tests? [galactosemia and
congenital hypothyroidism]

FEEDING HISTORY:

• Is the patient breast fed or formula? If formula why?

• What is the frequency and amount of the feed?
• Were there any changes in formula? If any why?

REVIEW OF SYSTEMS:

weight:
• What was the birth weight and did you observe any recent weight change ?

skin:
• Did you notice any pigmentation changes, bruising and bleeding?

HEENT:
• Did you observe the patient having any change in breathing pattern?

Cardiac:
• Did you observe the patient having any difficulty in breathing?

GI:
• Does the patient have diarrhoea or constipation?
• Did the patient have any episodes of vomiting? if yes, how frequent and what
is the consistency?

Musculoskeletal:
• Does the patient have fever?

FAMILY HISTORY

• Any previous siblings with neonatal jaundice, galactosaemia or congenital

hypothyroidism?
• Are there any other family members with jaundice?
• Any history of Anaemia or blood disorders in the family?
• Any history of splenectomies, bile stones or gallbladder removal in the family?
• Any maternal thyroid problems?

SOCIAL HISTORY

• what is the educational and occupational status of the parents?

• what is the source of the income to the family?
• Do u have any pets at home?
• what type of living conditions is family living in?

PHYSICAL EXAMINATION:

GENERAL SURVEY:

• What is the sensorium of the patient ?

• Is the patient cooperative or otherwise ?
• Is the patient in distress?
• Expected findings would assess need for immediate intervention or referral ?

VITAL SIGNS:

• Temperature (rectal)- hyperthermia or hypothermia ?

• Heart rate- tachycardia or bradycardia ?
• Respiratory rate- tachpneic or bradypneic ?
• Blood pressure - hypertensive or hypotensive ?

ANTHROPOMETRICS:

• Weight and height ?

• Occipital frontal circumference

SKIN AND LYMPHATICS:

• Turgor- instant recoil or >2 seconds ?

• Dicoloration of skin- Yellow or pale or bruising ?
• presence of spider nevi?

HEENT:

• Color of the eyes?

• Eye balls- slightly or deeply sunken?
• Check the parotids for any enlargements
• Check under the tongue for any yellow discolouration
• Clavicular nodes ?
• Encephalopathy ?

ABDOMEN:

• Gynecomastia ?
• Caput medusa?
• Hepatosplenomegaly?
• Murphy’s sign
• Palpable gall baldder
• Masses?
• Ascites?

MUSCULOSKELETAL:

• Color of the hand and foot- erythema

• Dupuytren’s contractures
• Clubbing?
• Asterixis?

NEUROLOGIC:

• Flapping tremors ?
• changes in muscle tone ?
• seizures ?
• microcephaly ?

CASE 2 : 9 month old, male with cough of 5 days

GENERAL INFORMATION: Patient name, age, gender, address, religion,

ethnicity, reliability and its percentage.

CHIEF COMPLAINT: What is the purpose of your visit?

HISTORY OF PRESENT ILLNESS:

• when did the cough start?

• how severe is the cough?
• What is the course of the cough (worsening, improving or fluctuating)?
• Is the cough constant or on and off?
• is the cough productive or non productive?
• If productive, what is the consistency, color and volume of the sputum?
• How frequent is the cough?
• Did the patient had fever or runny nose ?
• Did the patient had difficulty in breathing?
• What time of the day is the cough worst?
• Did the patient had night sweats?
• Did you observe any factors that trigger the cough?
• Did you take any measures to relieve the cough?
• Any previous episodes of cough? if yes, who did you consult? what was the
diagnosis? what was management? Did it work?
• what was the last meal?
• What pets or animals did the child have contact with?
• Any recent travel?

PAST MEDICAL HISTORY:

• Any major illnesses?

• Major surgical illness, operations and dates?
• Previous hospital admission with dates and diagnosis?
• Any recent respiratory infections?
• Any known asthma to the patient?
• Any current medications?
• Any known allergies?
• history of contact with an an individual who has TB?
• Was the patient vaccinated (bcG, 3 doses of HepB, 2 doses of rotavirus, 3
doses of DTaP, 2 doses of Hib, )?

PREGNANCY AND BIRTH HISTORY:

• Was there any maternal illness suggestive of viral or other?
• Was there any maternal medications, drug intake, alcohol or smoking?
• Any delayed cord clamping?
• Any birth trauma, bruising or fractures?
• What was the gestational age of the patient at delivery?
• what was the length of the labor?
• what is the type of delivery [vaginal or cesarean section]? if cesarean section,
why?
• what was the APGAR score?
• was there any need for intensive care? if yes, why?
• was there any hyperbilirubinaemia at birth? if yes, what was the
management?
• were there any feeding problems? if yes, why?
• what was the length of stay at hospital after birth?
• what was the birth weight of the patient?
• What is the maternal blood group?
• What were the results of new born screening tests?

DEVELOPMENTAL HISTORY:
• WHAT is the height and weight of the patient?
• Can he able to stand by himself?
• Does he have any sleeping problems?
• Can the baby babble?
• Can the baby pick up objects?
• Can he sit for long time and play with his toys?

FEEDING HISTORY:

• Is the patient breast fed or formula? If formula why?

• What is the frequency and amount of the feed?
• Were there any changes in formula? If any why?
• Did you introduce any solid food? if yes, At what age did you start?
• Did he face any problem with specific kind of food?

REVIEW OF SYSTEMS:

weight at birth and present weight

skin and lymph-

• Rashes
• pigmentation
• swollen lymph nodes?

HEENT-
• does the patient needed to breath through his mouth
• nasal discharge?

LUNG AND THORAX

• Did the patient had any difficulty breathing

GI-
• stool color character and odour?
• vomiting

Allergies-
• any known allergies?

FAMILY HISTORY:
• Any previous siblings with any respiratory illness?
• Any family members with respiratory illness?
• Any deaths in family; cause and age? Especially in infancy and childhood
• Any other medical illnesses?
• Do any conditions run through the family; allergy and asthma ,congenital
anomalies, cancer, hypertension, diabetes

SOCIAL HISTORY:
• Where do you live ?
• Is the baby under day care?
• How many people stay in your family?
• what is the occupation of parents?
• Do you have any pets?
• do anyone in the family smoke?

PHYSICAL EXAMINATION:

GENERAL SURVEY:

• What is the sensorium of the patient ?

• Is the patient cooperative or otherwise ?
• Is the patient in distress?
• Expected findings would assess need for immediate intervention or referral ?

VITAL SIGNS:

• Temperature (rectal)- hyperthermia or hypothermia ?

• Heart rate- tachycardia or bradycardia ?
• Respiratory rate- tachpneic or bradypneic ?
• Blood pressure - hypertensive or hypotensive ?
• oxygen saturation?

ANTHROPOMETRICS:

• Weight and height ?

• Occipital frontal circumference

SKIN AND LYMPHATICS:

• Turgor- instant recoil or >2 seconds ?

HEENT:

• Color of the eyes?

• Eye balls- slightly or deeply sunken?
• check for the presence and amount of nasal discharge
• check for the condition of nasal turbinates( pale, boggy or inflamed)
• check the pharynx for post nasal drip
• inspect the oropharynx
• palpate the lymph nodes of the head and neck( cervical and supraclavicular)

LUNGS AND THORAX:

• Inspect the chest- check for visible chest deformities

• palpate the chest- tenderness, symmetry, swelling and masses
• percuss the chest- (resonant, dull, tympanic)
• auscultate the chest- check for wheezing, crackles, rhonchi, decreased
breath sounds and signs of consolidation

ABDOMEN:

• palpate and check for tenderness (the baby may cry or irritable as he cant
express the pain)
• Masses?

MUSCULOSKELETAL:

• Clubbing?
• color of nail beds- cyanosis

NEUROLOGIC:

• Flapping tremors ?
• changes in muscle tone ?
• seizures ?
• microcephaly ?

CASE 3: 9 year old child, female with abdominal pain of 2

days

GENERAL INFORMATION: Patient name, age, gender, address, religion,

ethnicity, reliability and its percentage.

CHIEF COMPLAINT: What is the purpose of your visit?

HISTORY OF PRESENT ILLNESS:

• When did the pain start?

• Where exactly did the pain start and is the pain spreading to other parts?
• How severe is the pain?
• what does the pain feel like?
• What is the course of the pain (worsening, improving or continuing to
fluctuate)?
• Is the symptoms always present or does it come and go?
• what times of the day is the pain worse?
• Are there any triggering points for this pain?
• Does anything appear to improve the pain?
• What is the color, consistency and frequency of the urine and stool?
• Did you observe any blood in the urine or stool or vomitus?
• Did the patient had diarrhoea or constipation?
• Did the patient had any vomiting, fever or weakness?
• is there any change in the amount of fluid and food intake?
• what was her last meal before the symptoms start?
• Did the patient undergo any trauma?
• Any recent travel history?
• Has the patient experienced these symptoms previously? if yes, who did you
consult? what was the diagnosis? what was management?

PAST MEDICAL HISTORY:

• Any serious medical illness?

• Any previous operations?
• Any previous hospitalisations and why?
• Any present medication?
• Any known allergies?
• Immunisation

DEVELOPMENTAL HISTORY:

• what is the performance of the baby at school?

• Which extra curricular activities is she interested in ?
• communication effectiveness?
• any interpersonal relationship?

FEEDING HISTORY

• Liquid intake- (Water/milk/juices/carbonated drinks)

• What kind of food is mostly consumed
• snack choices-(junk/fruits/chocolates)

REVIEW OF SYSTEMS

• Any change in amount of food intake ?

• Any change in weight?

SKIN

• Rashes
• dryness
• suspicious lesions
• bruise and bleeding
• enlarged lymph nodes

CARDIOVASCULAR
• difficulty breathing
• chest pain

LUNGS AND THORAX

• cough

MUSCULOSKELETAL
• joint pains
• muscle pain

GU
• urinary frequency
• blood in urine
• difficulty in urination
• urinary incontinence?

FAMILY HISTORY

• Any previous siblings with any gastro intestinal illness?

• Any family members with gastro intestinal illness?
• Any deaths in family; cause and age? Especially in infancy and childhood
• Any other medical illnesses?
• Do any conditions run through the family; allergy and asthma ,congenital
anomalies, cancer, hypertension, diabetes
• what is the age of menarche of mother?

SOCIAL HISTORY:

• Where do you live ?

• Is the baby under day care?
• How many people stay in your family?
• What is the occupation of parents?
• Do you have any pets?
• Do anyone in the family smoke?

PHYSICAL EXAMINATION:

GENERAL SURVEY:

• What is the sensorium of the patient ?

• Is the patient cooperative or otherwise ?
• Is the patient in distress?
• Expected findings would assess need for immediate intervention or referral ?

VITAL SIGNS:

• Temperature (rectal)- hyperthermia or hypothermia ?

• Heart rate- tachycardia or bradycardia ?
• Respiratory rate- tachpneic or bradypneic ?
• Blood pressure - hypertensive or hypotensive ?
• oxygen saturation?
Skin:
• any ulcers or bruises, Rash, generalized or local to genital area

• Lymph node enlargement?

LUNGS AND THORAX:

• Inspect the chest- check for visible chest deformities

• palpate the chest- tenderness, symmetry, swelling and masses
• percuss the chest- (resonant, dull, tympanic)
• auscultate the chest- check for wheezing, crackles, rhonchi, decreased
breath sounds and signs of consolidation

Abdomen:
• inspect (scars, striae, vascular changes or protrusions)
• auscultate over all 4 quadrants(bowel sounds, bruits)
• percuss (tympanic, muffled)
• palpation of the abdomen(superficial and deep), rebound tenderness,
abdominal guarding
• palpation of liver -hepatomegaly
• palpation of spleen - splenomegaly
• palpation of inguinal lymph nodes
• percuss the liver
• liver scratch test
• fluid wave test
• CVA tenderness
• murphy sign

Rectal examination (bloody stools, possible focal impactions, question of

hirschsprung disease)

GU Examination:
• general examination of external genitalia
• gynaecological exam if necessary

CASE 4: 19 year Old, male with painful urination for 5 days

GENERAL INFORMATION: Patient name, gender, Date of birth, address, religion,

age, referral source(did anyone referred)

CHIEF COMPLAINT: What is the purpose of your visit?

HISTORY OF PRESENT ILLNESS

• when did the pain start?
• Where exactly is the pain?
• When does the pain start/worsen (before or after urination) ?
• What is the Character of pain ?( like sharp / dull ache / burning)
• Does the pain move to other areas?
• Is the pain on and off or continuous?
• what times of the day is the pain worse?
• Are there any triggering points for this pain?

• Does anything appear to improve the pain?

• What is the color, consistency and frequency of the urine and stool?
• Did you observe any blood in the urine or stool or vomitus?
• Did the patient had diarrhoea or constipation?
• Did the patient had any vomiting, fever or weakness?
• is there any change in the amount of fluid and food intake?
• Are they any previous episodes of the symptom?
• How severe is the pain ?(rate on a scale of 0-10)
• What is the time course ? (worsening / improving / fluctuating )

PAST MEDICAL HISTORY

• Any previous urological diseases? (like recurrent UTIs, renal stones,

Pyelonephritis, prostate cancer)
• Any previous surgical history?( cystoscopy / bladder surgery / renal surgery)
• Any other medical conditions ? (diabetes predisposes to UTIs ,any STIs)
• Any previous hospitalisations? If yes,When and why?
• Any previous medications,If yes brand and generic name, dosage?
• immunisation status?

REVIEW OF SYSTEMS

Weight : any recent changes in the weight?

Skin and Lymph :any skin ulcers, adenopathy, pigmentation changes?

GI : lower abdominal pain

GU: Frequency, dysuria, abdominal pains, polyuria, facial edema, hematuria,

previous infections

Musculoskeletal : Joint pains or swelling

FAMILY HISTORY

• Any urological diseases among the family members?

• Are the any Diabetic patients among the family members?

• Are parents still in good health? (if deceased sensitively determine age

and cause of death )

SOCIAL HISTORY

• Any smoking history? If yes How many cigarettes a day? How many years
have they smoked for?
• Intake of Alcohol,If yes How many units a week?  (type / volume / strength of
alcohol)
• Any Recreational drug use?

• Educational qualifications of the patient?

• Living situation of the patient? (type of house, with whom he stays)

• Any Occupational status of the patient?

SEXUAL HISTORY

• When was the Previous coitus ?

• Any history of STI ?
• Does the sexual partner have any STI or UTI conditions?

PHYSICAL EXAMINATION

GENERAL SURVEY

• Is the patient alert?

• Is the patient oriented and cooperative?

VITAL SIGNS:

• Temperature: hypothermia, normal or hyperthermia?

• Blood Pressure: hypotensive, normal or hypertensive?
• Pulse rate/ Heart rate : bradycardia, normal or tachycardia?
• Respiratory Rate: Tachpneic ,normal or bardypneic?

SKIN AND LYMPHATICS

• Skin: any ulcers or bruises, Rash, generalised or local to genital area

• Lymph node enlargement?

ABDOMEN
• Abdominal tenderness or mass? (Palpate and percussion of Abdomen (provide
information about kidney, ureter, or bladder inflammation)

• Tenderness over the costovertebral angle ? (If yes, it suggests pyelonephritis)

MUSCULOSKELETAL SYSTEM

• Acute joint effusions?

NEUROLOGIC

• neurogenic bladder?

GU/ RECTAL

• Any swelling or tenderness of epididymis or testicle?

• Any swelling or Tenderness of prostate?
• Enlarged symmetric prostate?
• Abnormality or hardness, asymmetry, nodule of Prostate?

-THANK YOU-