Sample Pediatric history writing : Vomiting and Diarrhoea
(This case
is special to me because this history is digital version of the history and
clinical examination I presented in my ninth semester pediatrics board examination.
Most of the points are just jotted down which needs linguistic description as
you present them. The parenthesized and italic words are the way it is said
while the words that are just parenthesized are the justification in any point
where extra elaboration may be needed. Many points may be missing but I have
not corrected the things I have written in the exam sheet. Since this was a piece of exam, so many points may be missing and complete elaboration is language is absent. So I would like to apologize for that.)
Name: Ms. Pariyar
Age:
11months
Sex: Female
Address:
Nala
Father: Mr. Pariyar, 23yrs Farmer, Class 7
Mother: Mrs. Pariyar, 21yrs housewife, illiterate
Informant: Mother, hence reliable.
(Always
write the level of education and profession of parents to know the level of
their comprehension and their approach to child health. The informant is
important as mother is the one who take cares of the child and knows the exact chronology
and series of event. While other informants such as father, grandparents are not
the first hand handler of the child and may only elaborate what they have been
told by the mother and may not know all the details.)
Date of
admission: 23rd September 2015 to ER @ 2:00pm
Date of
Examination: 24th September 2015
(Ms. Pariyar, 11yrs girl from Nala, daughter
of Mr and Mrs pariyar was presented to DH ER yesterday at 2:00 pm with
complains of )
Chief Complaints
Vomiting for 5 hours x 1 day
Diarrhoea for 1 day
(The history is given by mother, hence the
history is reliable)
History of Present illness
According to the mother, the child was active and playful 2 days back,
then she developed 8-9 episodes of vomiting, which initially contained the
ingested food material (milk) and later turned greenish and watery. It was
about 2 teaspoon full in each episode, foul smelling and non-projectile.
After around 6 hours, the child developed diarrhea, 10-12 episodes/day,
watery with mucoid content, was foul smelling but did not contain blood in the
stool. The child cries while passing the stool but not during micturition.
There is also history of fever associated with diarrhea which was
mild, continuous and not associated with rash and abnormal body movement.
There is no loss of appetite, drinks vigorously. Mother gives history
of infrequent micturition compared to previous times.
No cough, no shortness of breath.
No loss of consciousness or avoidance of bright light.
Treatment history:
The patient
was bought to DH 2 hours after the onset of vomiting, where she was provided
with IV medication which subsided the vomiting. The child has been receiving IV
fluids and the child is improving as vomiting has subsided but diarrhea is yet
to improve.
Past history
Birth
ANC: 6 ANC visits, taken folic acid,
iron, calcium, 2 TT vaccines.
Natal: Cesarean delivery at DH for
prolonged labor, cried immediately after birth, passed stool and urine within
24 hours.
Post natal: breastfed within 24 hours
of birth.
(The
mother had regular ANC visits and had taken folic acid, iron, calcium and both
the TT vaccine. She underwent CS at DH for prolonged delivery. The child cried
immediately after birth, the child cried immediately after birth, passed stool
and urine within 24 hours. The child was breast fed within 24 hours of birth. The
post natal period was uneventful.)
(The child greater than 3 years all the
prenatal, natal and postnatal history may be uneventful and can be skipped without
telling the minor details unless it has significant relation to birth history.
The child is breast =fed generally within 1 hour of birth but since this a CS
case, so the breastfeeding may have been delayed.)
Immunization
At birth BCG
6 weeks Hep B, Hib, DPT, OPV, PCV
10 weeks Hep B, Hib, DPT, OPV, PCV
14 weeks 2 vaccines Hep B, Hib, DPT,
OPV, IPV (2 vaccine is the description given by mother, Pentavalent in one
vaccine and IPV in the next)
9 months MR + PCV
12 months and 15 months remaining.
(The child has received the vaccination as
per the National EPI Schedule for her age, the vaccinations of 12 months and 15
months are remaining.)
(All the
vaccine mentioned need not be read one by one, rather National EPI Schedule
includes all. Mother can describe at what age, how many shots of vaccine and
oral drops the child has received. Based upon that we can confirm If the child
has received the necessary vaccination or not.)
Nutrition
Exclusively Breastfed for 1
month
Then added powder milk
After 3 months: Sarbottam pitho
Currently Breastfed every 1-2 hourly
for 10-15 minutes
Dal + rice small bowel 100X2 gm = 200
gm calorie: 260 kcal
Snack Biscuit 3 pieces 3x 20 = 60kcal
Total 340 kcal
8 kg 800 kcal
(The child was exclusively breastfed for 1
months and then weaned with powder milk. After 3 months of age sarbottam pitho
was added to her diet. Currently she is breastfed every 1-2 hour for duration
of 10-15 minutes. Besides she is fed with 2 small bowel of regular meals and 3
pieces of biscuit in snack. The total calorie intake besides breast milk is 340
kcal and the expected calorie intake needed is 800kcal)
(Calorie
deficit can not be commented upon as the chold is still feeding on milk. If
breast milk does not form the significant source, the calorie defecit must be
calculated)
Development
Stands with support and walks with
support (Motor)
Pincher grasp present (Fine Motor)
Uses bisyallable words and says baba
and ama (language)
Interacts with mother (Social)
Past History
No history of similar illness in the past.
No chronic
illness like asthma.
Family history
Mother had similar illness 1 week back.
No history of chronic illness.
(Pedigree drwaing is must in pedia, see the image)
Socioeconomic history
Belongs to a
well sustained middle class family.
Has provision
of sanitary latrine and uses soap.
Drinks water
from tap and spring water but does not boil the water.
Drug and
Allergy history: Not present
History of
Consanguinity: Not present
History of
Contact to TB: Absent
Examination
Ill looking,
fairly built child, is lying in supine position with yellow IV cannula with fluid
flowing through the cannula.
Vitals
Pulse:
136bpm, regular euvolemic
BP: (not
feasible)
RR: 47bpm ,
regular, thoracoabdominal
Temperature :
38oC
Anthropometry
Length: 74cm, which lies between the 10th and 25th centile.
HC (head
circumferene): 46 cm lies between the 10th and 25th
centile
Weight: 8 kg
MUAC : 14cm
(Mid Upper Arm circumference)
(The
anthropometry data are plotted in a standard growth chart and the centile is
measured or the expected values of various can be measured using various
formula and the percentage of the expected and the observed can be calculated.)
>>Learn normal anthropometry values and formula to calculate them in pediatric.
>>Learn normal anthropometry values and formula to calculate them in pediatric.
Head to Toe examination
Hair looks
normal in color and texture.
Fontanels
are not sunken.
No discharge
and redness of eyes
No dryness
of eyes or sunken eyes
No nasal discharge
and congestion
Mouth and
oral cavity looks normal with 2 lower incisors and 1 upper incisors
Skin surface
looks normal
No icterus,
pallor or cyanosis.
Hydration
status looks normal.
Abdominal examination
On inspection
The abdomen
is protuberant and the umbilicus is centrally placed. All quadrants moving correspondingly
with respiration. No visible pulsation, peristalsis or scar marks.
All quadrant
moving corresponding with respiration.
Hernial
orifices intact.
Perianal
erythema present.
On palpation
Abdomen is
soft, non tender and no local rise in temperature.
On superficial
palpation, no masses palpable.
Liver is
palpable 2 cm from the right costal margin which is soft, non tender and the
margin is regular.
Spleen is
not palpable and kidneys are not ballotable.
Kidneys are
not ballotable.
On percussion, normal tympanic note is
present all over the abdomen
On auscultation, normal bowel sound
heard with 3 bowel sound/minute heard.
Chest: B/L
equal air entry with normal vesicular breathe sound (NVBS). S1S2M0
CNS/MSK:
Grossly intact
Provisional diagnosis: Acute Gastroenteritis
Differential Diagnoses: Enteric Fever
Viral
Hepatitis
Secretory
Diarrhoea
