Identifying Data: Patient's name, age, sex; significant medical conditions,
informant (parent).
Chief Compliant (CC): Reason that the child is seeking medical care and
duration of the symptom.
History of Present Illness (HPI): Describe the course of the patient's illness,
including when and how it began, character of the symptoms; aggravating or
alleviating factors; pertinent positives and negatives, past diagnostic testing.
Past Medical History (PMH): Medical problems, hospitalizations, operations;
asthma, diabetes.
Perinatal History: Gestational age at birth, obstetrical complications, type of
delivery, birth weight, Apgar scores, complications (eg, infection, jaundice),
length of hospital stay.
Medications: Names and dosages.
Nutrition: Type of diet, amount taken each feed, change in feeding habits.
Developmental History: Age at attainment of important milestones (walking,
talking, self-care). Relationships with siblings, peers, adults. School grade and
performance, behavioral problems.
Immunizations: Up-to-date?
Allergies: Penicillin, codeine?
Family History: Medical problems in family, including the patient's disorder;
diabetes, seizures, asthma, allergies, cancer, cardiac, renal or GI disease,
tuberculosis, smoking.
Social History: Family situation, alcohol, smoking, drugs, sexual activity.
Parental level of education. Safety: Child car seats, smoke detectors, bicycle
helmets.
Review of Systems (ROS)
General: Overall health, weight loss, behavioral changes, fever, fatigue. Skin: Rashes, moles, bruising, lumps/bumps, nail/hair changes. Eyes: Visual problems, eye pain.
Ear, nose, throat: Frequency of colds, pharyngitis, otitis media. Lungs: Cough, shortness of breath, wheezing. Cardiovascular: Chest pain, murmurs, syncope.
Gastrointestinal: Nausea/vomiting, spitting up, diarrhea, recurrent abdominal pain, constipation, blood in stools.
Genitourinary: Dysuria, hematuria, polyuria, vaginal discharge, STDs. Musculoskeletal: Weakness, joint pain, gait abnormalities, scoliosis. Neurological: Headache, seizures.
Endocrine: Growth delay, polyphagia, excessive thirst/fluid intake, menses duration, amount of flow.
....CLICK HERE TO DOWNLOAD FULL ARTICLE
Showing posts with label Pediatrics. Show all posts
Showing posts with label Pediatrics. Show all posts
Monday, April 6, 2009
Sunday, April 5, 2009
General Pediatrics 2
In children there is a physiologic anemia. Often it occurs - it peaks between 2 and 3 months of age. Most children will get down to a range of around 11 in about 3 months. Some people advocate screening between 9 and 12 months. It’s a peak age for iron deficiency if they have switched off iron formulas. Some people advocate 24 months. Another point is that if you do a peripheral hematocrit it could be lower than central so that if they are anemic, you should probably do a central test. Just a picture of a tiny child that can show up. Pale mucous membrane, pale skin. You see what are called red lines, concentrated dense lines at the growth centers.
Lead Poisoning. In the 1980’s the average lead level was about 12. In 1991 the average lead level in our population was 3. Leaded paint has been eliminated for the most part in this country, but even today some paint is still leaded. Leaded gasoline, industrial lead, and car batteries and then all this miscellaneous. Sometime lead-containing ceramic vessels. The point is that young children are particularly at risk for lead poisoning because of their hand-to-mouth exposure. And also through the respiratory tract. In the past we used to use the erythrocyte protoporphyrin test as a screen. It’s no longer recommended. It was only useful when sort of there were a lot of levels above 30. Venous lead level is the test to use. You do a finger first and then you do a venipuncture if it’s elevated. And the big news is, as most of you know this, is that we have
lowered our level of what’s acceptable. Any child that’s screened that has a level of 10, an environmental assessment needs to be done.
....CLICK HERE TO DOWNLOAD FULL ARTICLE
Lead Poisoning. In the 1980’s the average lead level was about 12. In 1991 the average lead level in our population was 3. Leaded paint has been eliminated for the most part in this country, but even today some paint is still leaded. Leaded gasoline, industrial lead, and car batteries and then all this miscellaneous. Sometime lead-containing ceramic vessels. The point is that young children are particularly at risk for lead poisoning because of their hand-to-mouth exposure. And also through the respiratory tract. In the past we used to use the erythrocyte protoporphyrin test as a screen. It’s no longer recommended. It was only useful when sort of there were a lot of levels above 30. Venous lead level is the test to use. You do a finger first and then you do a venipuncture if it’s elevated. And the big news is, as most of you know this, is that we have
lowered our level of what’s acceptable. Any child that’s screened that has a level of 10, an environmental assessment needs to be done.
....CLICK HERE TO DOWNLOAD FULL ARTICLE
Cardiovascular Disorders in Pediatrics
Congenital heart disease occurs in about 1% of children. Heart murmurs are much more common, and may be heard in virtually every child if examined carefully.
I. Clinical Evaluation of Cardiovascular Disorders
A. History
1. For neonates, a history of feeding problems, cyanosis, tachypnea, irritability or grunting respirations may indicate serious cardiac pathology. A history of feeding less than 2 ounces at each feeding in a term infant may indicate pathology. A family history of congenital heart disease may be helpful, but the
incidence of congenital heart disease in families where the mother has
congenital heart disease is only 5-10%. 2. For older children, it is unusual for a pathologic murmur to present for the first time outside of infancy. Two notable exceptions are hypertrophic cardiomyopathy and murmurs associated with dilated cardiomyopathy.
Symptoms which indicate serious pathology include exercise-induced chest pain, exercise induced syncope, or cyanosis. Easy fatigability is non specific, and not helpful in differentiating pathologic from non-pathologic murmurs.
B. Physical Examination
1. Congenital heart disease is more common in infants with congenital anomalies.
Trisomy 21. The incidence of heart disease is about 50% in these children. Anomalies include
ventricular septal defects, atrioventricular canal defects,
and patent ductus arteriosus.
b. Trisomy 18. The incidence of heart disease is almost 100%in these children. Ventricular septal
defect is the most common anomaly.
c. Trisomy 13. The incidence of heart disease is about 80%, usually VSD.
d. Turner syndrome (coarctation, hypertension), Marfan syndrome (aortic
aneurysms), and Noonan syndrome (pulmonic stenosis, coarctation) are other congenital
anomalies.
2. Growth parameters may suggest failure to thrive that is caused by cardiovascular disease. Infants with cardiovascular disease usually have a
normal head circumference, and height may be normal, but the weight is usually lower than anticipated.
3. Blood pressure determination. All children 3 years of age and older should have their blood pressure measured on a yearly basis. The blood pressure cuff should be appropriate for the patient’s size. The width of the cuff should be at least 2/3 the length of the upper arm, and the bladder should be long enough to almost encircle the upper arm. Blood pressure levels vary depending on the
age of the child, and hypertension is defined as a blood pressure consistently greater than the 95th percentile for age.
a. Presenting symptoms of severe hypertension in infants include congestive heart failure
(caused by coarctation), respiratory distress, and failure to thrive.
b. Symptoms of severe hypertension in older children may include headache, nausea, vomiting,
mental status changes, and epistaxis.
4. Cardiovascular Examination
a. Inspection
(1) Conditions that cause cardiac enlargement (ventricular septal defect,
The recommendations in blood pressure management are from the National High Blood Pressure Education Project provides tables that will give you normal data for blood pressure that varies by age, by height of the patient. Blood pressure should be measured in all children greater than three years of
age. Blood pressure should be measured from the patient's right arm after they
have been sitting in a quiet room for three to five minutes. Blood pressure should be measured twice and the results averaged, and the blood pressure should be measured with an appropriate size cuff. The simplest way to remember that is to try and get the largest cuff you can get on the child's arm.
They recommend that in a pediatric practice you have six cuffs. Three small
cuffs, one adult cuff, a large adult cuff and then a thigh cuff.
For definition of the diastolic blood pressure, the fifth Korotkoff sound is used. The fifth sound is when the sound totally disappears. There are patients in
whom the fifth Korotkoff sound never occurs. In other words, the sound never disappears, but then if it goes all the way down to zero, they don't have diastolic
hypertension, which makes sense.
Hypertension is defined as a child that has an average systolic or diastolic
blood pressure greater than the 95th percentile on three separate occasions, not all done in the same day. So don't rush into the diagnosis of hypertension.
Most children that have modest elevations in blood pressure are overweight and possibly have a family history of high blood pressure. Those people might get just a very basic routine screening evaluation which might include a urinalysis (looking for casts, hematuria, proteinuria), a BUN creatinine, looking
for elevation of creatinine consistent with renal disease, and also a good
cardiac physical exam, feeling femoral pulses. Those people would be treated with weight reduction, dietary restrictions, and emphasis on physical activity. Patients should not be restricted from physical activity because of mild elevations in blood pressure.
People that have significantly elevated blood pressure, and these are the people in the 99th and above percentile, frequently have underlying disease that is causing their hypertension. It is not idiopathic or familial hypertension. The two organ systems that are most commonly implicated are the renal
system and the cardiovascular system. Remember to listen for bruits over the abdomen because renal artery stenosis is a fairly common cause of significant
hypertension in children, and remember to feel the femoral pulses.
Now, I am going to briefly go over the cardiovascular exam, specifically the acyanotic category for an atrioseptal defect (ASD). In order to diagnose an
ASD it is not what is outside your ears that is most important. It is what is
between your ears that is most important. You need to know what you are listening for. If you can do a good ASD exam, then you know how to use your stethoscope. If you can rule out an ASD every time you listen to a patient, you will refer many fewer functional murmurs for evaluation, and you will miss many
fewer ASDs.
..... CLICK HERE TO DOWNLOAD FULL ARTICLE
I. Clinical Evaluation of Cardiovascular Disorders
A. History
1. For neonates, a history of feeding problems, cyanosis, tachypnea, irritability or grunting respirations may indicate serious cardiac pathology. A history of feeding less than 2 ounces at each feeding in a term infant may indicate pathology. A family history of congenital heart disease may be helpful, but the
incidence of congenital heart disease in families where the mother has
congenital heart disease is only 5-10%. 2. For older children, it is unusual for a pathologic murmur to present for the first time outside of infancy. Two notable exceptions are hypertrophic cardiomyopathy and murmurs associated with dilated cardiomyopathy.
Symptoms which indicate serious pathology include exercise-induced chest pain, exercise induced syncope, or cyanosis. Easy fatigability is non specific, and not helpful in differentiating pathologic from non-pathologic murmurs.
B. Physical Examination
1. Congenital heart disease is more common in infants with congenital anomalies.
Trisomy 21. The incidence of heart disease is about 50% in these children. Anomalies include
ventricular septal defects, atrioventricular canal defects,
and patent ductus arteriosus.
b. Trisomy 18. The incidence of heart disease is almost 100%in these children. Ventricular septal
defect is the most common anomaly.
c. Trisomy 13. The incidence of heart disease is about 80%, usually VSD.
d. Turner syndrome (coarctation, hypertension), Marfan syndrome (aortic
aneurysms), and Noonan syndrome (pulmonic stenosis, coarctation) are other congenital
anomalies.
2. Growth parameters may suggest failure to thrive that is caused by cardiovascular disease. Infants with cardiovascular disease usually have a
normal head circumference, and height may be normal, but the weight is usually lower than anticipated.
3. Blood pressure determination. All children 3 years of age and older should have their blood pressure measured on a yearly basis. The blood pressure cuff should be appropriate for the patient’s size. The width of the cuff should be at least 2/3 the length of the upper arm, and the bladder should be long enough to almost encircle the upper arm. Blood pressure levels vary depending on the
age of the child, and hypertension is defined as a blood pressure consistently greater than the 95th percentile for age.
a. Presenting symptoms of severe hypertension in infants include congestive heart failure
(caused by coarctation), respiratory distress, and failure to thrive.
b. Symptoms of severe hypertension in older children may include headache, nausea, vomiting,
mental status changes, and epistaxis.
4. Cardiovascular Examination
a. Inspection
(1) Conditions that cause cardiac enlargement (ventricular septal defect,
The recommendations in blood pressure management are from the National High Blood Pressure Education Project provides tables that will give you normal data for blood pressure that varies by age, by height of the patient. Blood pressure should be measured in all children greater than three years of
age. Blood pressure should be measured from the patient's right arm after they
have been sitting in a quiet room for three to five minutes. Blood pressure should be measured twice and the results averaged, and the blood pressure should be measured with an appropriate size cuff. The simplest way to remember that is to try and get the largest cuff you can get on the child's arm.
They recommend that in a pediatric practice you have six cuffs. Three small
cuffs, one adult cuff, a large adult cuff and then a thigh cuff.
For definition of the diastolic blood pressure, the fifth Korotkoff sound is used. The fifth sound is when the sound totally disappears. There are patients in
whom the fifth Korotkoff sound never occurs. In other words, the sound never disappears, but then if it goes all the way down to zero, they don't have diastolic
hypertension, which makes sense.
Hypertension is defined as a child that has an average systolic or diastolic
blood pressure greater than the 95th percentile on three separate occasions, not all done in the same day. So don't rush into the diagnosis of hypertension.
Most children that have modest elevations in blood pressure are overweight and possibly have a family history of high blood pressure. Those people might get just a very basic routine screening evaluation which might include a urinalysis (looking for casts, hematuria, proteinuria), a BUN creatinine, looking
for elevation of creatinine consistent with renal disease, and also a good
cardiac physical exam, feeling femoral pulses. Those people would be treated with weight reduction, dietary restrictions, and emphasis on physical activity. Patients should not be restricted from physical activity because of mild elevations in blood pressure.
People that have significantly elevated blood pressure, and these are the people in the 99th and above percentile, frequently have underlying disease that is causing their hypertension. It is not idiopathic or familial hypertension. The two organ systems that are most commonly implicated are the renal
system and the cardiovascular system. Remember to listen for bruits over the abdomen because renal artery stenosis is a fairly common cause of significant
hypertension in children, and remember to feel the femoral pulses.
Now, I am going to briefly go over the cardiovascular exam, specifically the acyanotic category for an atrioseptal defect (ASD). In order to diagnose an
ASD it is not what is outside your ears that is most important. It is what is
between your ears that is most important. You need to know what you are listening for. If you can do a good ASD exam, then you know how to use your stethoscope. If you can rule out an ASD every time you listen to a patient, you will refer many fewer functional murmurs for evaluation, and you will miss many
fewer ASDs.
..... CLICK HERE TO DOWNLOAD FULL ARTICLE
Subscribe to:
Posts (Atom)
