*Practical pediatric lecture-2-
*Monday(26-10-2015) Sample of History takingاحمد ظاهر Name :-
Age :-11 monthsAddress:-wasety.
Source of taking the history :-his mother.
Date of Taking history:-26/10/2015 .
Date of admission:-25/10/2015 at the afternoon time.
History of consanguinity :- +
C.c:-increased body temperature of *2* days duration.
H.P.I:-11months old male infant , admitted to hospital since *8* days ,as he developed increased body temperature associated with sweating ,but no chills ,the pattern is continous through the day , relieved by medication at home, then after 4days he developed change in bowel motion by passing of watery stool not containing blood but contain mucus , not associated with feeling of incomplete emptying,frequency unknown ,amount:-small amount ,he has poor feeding,poor relactant to feeding,marked wt loss in the last two months (unknown how much he lost),no associated vomiting ,nausea or regurgitation but there is sleep disturbance.so they admitted him to hospital ,they performed for him:GSE,lumbar puncture with administration of I.V fluid & anti-diarrheal agents(unknown),he became well & was discharged.
After *2*days he again developed increase in his body temperature,they took him to the out clinic doctor ,he referred him to hospital,here they administered I.V fluid with anti-pyretic agents.
Developmental Hxnote :don't take it at the acute time of illness.
He can roll over ,smile , he is oriented to the surrounding, can say very few words*speech is retarded*,he can't sit,he crawls on his abdomen for little distance,he can couch the objects .The expected developmental age is 6-7months,He has normal development till the age of 5months then he begin to regress
Peri natal Hx :-
--prenatal:-the Age of mother is 35 yrs old,she has anemia during pregnancy diagnosed before labour as they administered 1 bottle of blood to her,she hasn't any other diseases in pregnancy (G.D.M & hypertension) ,she had morning sickness but not so severe(mild),she is not smoker & she had bad ante natal care,no medications were received in pregnancy,she hadn't received any vaccine,no History of infertility,no history of x-ray exposure.
--natal:-he was delivered by CS indicated because of oligohydraminos
He was 30wks (G.A),delivered at hospital,smooth postpartum period.-- Post natal:-
His wt at birth was 3kg,post natal period went smoothly without any illness apart from jaundice.Family history:-
His mother age is 35yrs old ,good health status,his father age is 45yrs old also good health status.consanguinity between parents is +
The number of the child pt(infant)in the family:3 children
Number of sibling:-2 (boys)
similar condition in other member of the family :-his greater brother has the same condition (regression in developmental age after a period of normal development).
Feeding Hx:-
Type of feeding:-at fist *5*months,he was breast feeding dependent,after that due to his chronic illness ,the dr.prescribed bottle feeding.Sign of satisfaction:-he refuses the bottle.
Frequency &amount (duration in breast milk):-(unknow)
How many bottle she has? unknown
Mode of sterilization of bottles feeding:-by hot water.
Introduction of added food ?she had introduced solid foods when he was 5 months but withdrawal them because of recurrent illness (diarrhea).
Past Hx:-
--past medical:-
Hx of any chronic disease is present(hyperthyroidism).
time of Dx:-since 3 days.
till now no Medications used to treat it
good Medical follow up for that disease :
there is Hx of infectious dis(recurrent diarrhea).
there is Hx of previous hospitalization since he was 6th months age ,he admitted for having diarrhea& fever,they treat him by I.V fluid & some medications
no Hx of allergy (asthma,eczema,hay fever)