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PCs & HPCs

Name:
Age:
Gender/race:
Nature of referral (showing severity):
(GP referral,Booked patient,Self referral,Brought in by ambulance or parents,Came

Complaint:
Background input (any contributory of the illness, if necessary):
(28days of prematurity --> predispose to bronchiolitis)

Presenting complaint:

Fever
1. Type (Cont./Remit/
Intmint./Relapse)
2. Character
3. Duration
(sudden/gradual)
4. Nocturnal Variation
walking)
5. Chills/Rigor?
6. Rashes/Joint Pain
7. Frequency/Recurren
t
8. Temperature
9. Medication
10. Hx Contact
11. Hx Travel
12. Fits?

Nur Nadi 2 years old malay girl, GP referral to ED of HSB with complaint of
fever a/w 2 day history of cough and with background of 28 days prematurity.
History of presenting illness (HOPI):

Cough
Duration
Sound
SOB?
Cyanosis
Type (Productive?)
Sputum Character
PostTussive
(Condition)
8. Runny nose
9. Frequency
10. Exacerbating/Rel
ieving
11. Medication
1.
2.
3.
4.
5.
6.
7.

1.
2.
3.
4.
5.
6.
7.
8.
9.

Vomitting
Frequency
Characteristics
Volume
Projectile/NonProjctl
e
Hematemesis
Duration
Exacerbating/Reliev
ing
Timing
Nausea

Fits
1. Type
(myoclonic,tonicclonic,tonic,clonic,abs
ence)
2. Duration
3. Frequency
4. Episode
5. Characteristics
6. PreIctal/Ictal/PostIctal

Systemic reviews
General health

1.
2.
3.
4.
5.
6.
7.
8.
9.

Diarrhea
Appearence
Frequency
Amount
Character
Dysentry
Rashes
Pain
Abd. Distension
Flutulance

1.
2.
3.
4.
5.
6.

Pain
Site
Onset
Characteristic
Radiation
Associated Sympt
Time

Nutritional and hydrational status,

LOA & LOW


Jaundice
Rashes
Fever

Genitourinary system
Polyuria
Nocturia
Hematuria
Vaginal discharge
Bleeding,
Flank pain

Cardiovascular system
Palpitation
SOB
Chest pain
Syncope

Central nervous system


Headache
Dizziness
Loss of consciousness
Visual
Hearing disturbances

Respiratory system
Runny nose
Cough
wheeze,
SOB
activity limitation
Chest pain
Haemoptysis

Musculoskeletal system
Arthralgia
Myalgia
Muscle cramps

Gastrointestinal system
Dysphagia
Nausea
Vomiting
Abdominal pain
Diarrhea
Constipation
Melena
Hemetemesis

Endocrine system
Profuse sweating
Polydipsia
Hot or cold intolerance
Haematological system
Fatigue or pallor
Bleeding tendencies

Past medical history


Is it the first admission
Any previous diseases
(when, investigation done, management)
(used to have Ventral Septal Defect, at 2008(when), using ultrasound (investigation done), what given
medication (management))

Any surgical done


Allergies (to drugs or food)

Birth History
Natal (Method Dilvry, BWt, Crying?)
Antenatal (Dz, Prgncy Term?, Medications?)
PostNatal (Complications, Dz)
Immunization
Vaccination

Age (months)

School
(years)

birt
h

1
0

1
1

1
2

18

BCG Bacille Calmatte-

acellular Pertusis

IPV Inactivated Polio


Vaccine
HiB Haemophilus Influenza
Type B

1
3

DT
B+
B+

T
B+

B+

Measles (Sabah)
MMR Measles, Mumps,
Rubella

JE (Swk) Japanese
Encephalitis
HPV Human Papilloma
Virus

B+: Booster dose; B*: Booster at 4 years age; DT: Diphtheria

Feeding history
Breastfeed (how long?)
Weaning (when, what type)
Amount
Time/Frequency
Diet

Developmental history

15

xsc
ar

Guerin

Hepatitis B
DTaP Diphtheria, Tetanus,

B*
3
x

Family history (do genogram for Dr Masri CWU)


(asthma, DM, allergies, cancer, early neonatal death, common genetic disorder)
Family Hx
Siblings
Parents
(Assoc Illness, education)
Consanguinity

Social and Environmental history


Who the child live with
What type of the house (carpet, pets, surrounding air)
Marital status
Smoker, alcohol, substance abuse
Working
Salary
Nursery
Social Hx
Parents Occupation
House type, pets, carpet
Hx of contact (daycare, siblings)
Travel
School/Daycare
Effect of illness

History of contact
(esp in patient with common cold, diarrhea and vomiting, leptospirosis, dengue (hotspot), scabies
(boarding school) --> family or friends, close contact with)

Summary

Physical Examination
General examination
Introduce
General appearance
Dysmorphic features
Hands
Warm peripheries
Pallor of palmar creases
Palmar erythema
Clubbing
Capillary refill time <2sec
Pulse rate (15s x 4, regular/irregular rhythm, volume)
(for radiofemoral delay, applicable in CVS, not in general exam.)
Blood pressure (in exam --> i would like to assess the BP)
Face
Eye
Conjunctiva pallor
Jaundice of sclera
Mouth
Buccal mucosa moist/dry
Oral hygiene is good/poor
Central cyanosis
Tonsils are enlarged/not enlarged
Ears and nose
Any discharge
Neck
Lymph nodes
Proceed with axilla and groins lymph node if necessary
Legs
Edema
Rashes or any lesion on skins

Abdominal Examination
Position the patient flat
Adequate exposure (from mid nipple line to mid thigh, but due to patient modesty, only exposed
up to suprapubic region)
Inspection
Abdominal is distended/not
Presence of any surgical scars
Palpate
Light
Abdomen is soft/hard and non tender/tender
Deep
Liver from right iliac fossa upward
Spleen from right iliac fossa upward obliquely to right, troubes space
Kidney balotable
Auscultate
Normal/abnormal bowel sound