PAEDIATRIC CLINICAL HISTORY TAKING AND PHYSICAL EXAMINATION
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Module
Cmt 201 (A21)
Institution
Primary Health Care Institute-Iringa
This book/note describe how to take clinical history from pediatric patient and how to do physical examination so as to obtain diagnosis and differential diagnosis and start to manage patient properly.
Also it has define some of medical terminology which are important during taking medical histo...
isakabartholomew@gmail.com
(for more consultation and question)
Understanding
Paediatric History
Taking and Physical
Examination
UPHTPE
ISAKA MWELANGE
5/12/2023
,Table of Contents
MEDICAL HISTORY TAKING ................................................. 4
1. DEMOGRAPHIC DATA OR PATIENT PROFILE ................... 6
2. CHIEF COMPLAINT (C/C) ................................................. 9
3. HISTORY OF PRESENT ILLNESS (HPI) ............................. 10
4. REVIEW OF OTHER SYSTEM [ROS] ................................ 14
5. PAST MEDICAL HISTORY [PMD] .................................... 15
6. NATAL ............................................................................ 16
7. POSTNATAL ................................................................... 16
8. IMMUNIZATION AND MCH CARD NO 1 ........................ 16
9. NUTRITION HISTORY ..................................................... 16
10. DEVELOPMENT HISTORY ............................................. 17
11. FAMILY AND SOCIAL HISTORY [FHS] ........................... 17
SUMMARY 1 ...................................................................... 17
12. GENERAL EXAMINATION ............................................. 18
13. SYSTEMATIC EXAMINATION [START WITH SYSTEM
AFFECTED FIRST] ............................................................... 20
14. DIAGNOSIS AND DIFFERENTIAL DIAGNOSIS ............... 27
15. MANAGEMENT OF A PATIENT .................................... 27
Reference .......................................................................... 29
1
, SIGN AND SYMPTOMS
SIGN
Is an effect of a disease than can pick by a medical personnel
example sunken eyes, yellowish discoloration of sclera,
moderate conjunctivae paleness. The most important
medical signs are called vital signs which include pulse rate
(beats/min), respiratory rate (breath/min), temperature
(Celsius/Fahrenheit), blood pressure (Mmhg) and oxygen
saturation. Also these vital signs are closely monitored during
an operation.
Pathology has four different signs, which are as follows.
Diagnostic signs are one that helps a doctor to
diagnose a medical problem. On days with high
pollen counts, if you find yourself congestion,
constantly sneezing, and with itchy red eye, these are
diagnostic signs of a pollen allergy.
Pathognomic signs are the same as a diagnostic sign
but with much greater certainty. An example of
pathognomic sign is a bronze like skin pigmentation
caused by Addison’s disease.
Prognostic signs are signs that predict the
improvement or outcome for a patient. Medical
personnel/ doctor use prognostic sign to predict
what will happen to a patient. Example a patient was
diagnosed with paralysis of left upper limb, after a
time patient start to flex and extent left upper limb
2
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