Paediatric Clinical Examination - Essay Example

"Paediatric Clinical Examination" is a great example of a paper on child development. A 2-month-old infant presenting with decreased feeding, fever, and fussiness. The mother noticed fussiness a day ago that continued to get worse. The child has not been waking up to breastfeed at night. She has only breastfed four times for the past 24 hours. The baby is hot to the touch with a skin temperature of 104F. The mother as well claimed that the baby was ever fussier in the day. The baby is lethargic and cries a lot. She has dry skin that looks dehydrated. The mother became concerned about the infant's state, gave her some paracetamol for temperature regulation before taking her to the hospital. The mother claims that the infant has not had any cough, wheezing, diarrhea, or vomiting.

Past Health history
Childhood illnesses: UTI and SVT 3 weeks age
Serious Accidents of Injuries: None
Serious or Chronic Illnesses: None
Operations of Hospitalizations: None
Immunizations
Birth - HepB
2 months - RV, DTaP, Hib, PCV, IPV
Allergies: no known drug or food allergies
Medications: Propranolol 4.5mg/kg/day 8 hourly

Developmental History: She can hold her head steady when being held. She can turn her head from side-to-side. She can follow objects beyond her nose. She is startled by strident noises. She recognizes her mom’s face and smiles when prodded.

Growth: Wt- 5.6kg (70th %) Length- 58cm (75th %) HC- 38.cm (50th %)
Milestones: The baby smiles, coos, and bubbles
Current development: Attempts to roll over
Family History
Maternal Grandmother- Hypertensive with diabetes mellitus type II
Maternal Grandfather- Deceased at 65 years due to heart failure
Paternal Grandmother- 60 years old with Cardiomyopathy
Maternal Grandfather- 56 years old Asthmatic on treatment
Mother- 27yeras old and normal, no chronic illness
Father- Diabetic, and Obese on diabetic treatment and diet modification
Aunt- Normal

Review of Systems
General: The child is healthy and happy, good sleep patterns decreased feeding and fever
Skin: Slight rashes at the buttocks, no jaundice, and slight dehydration
Head: No trauma, normal head size. Well distributed hair
Eyes: no discharge, no jaundice, no conjunctivitis
Ears: no discharges
Nose and sinuses: Patent nostrils, no discharges
Mouth and Throat: No teeth, no enlarged tonsils, no cleft palate
Neck: No stiffness, no lymphadenopathy
Respiratory System: Difficulty in breathing
Cardiovascular System: No cyanosis, no murmurs
Gastrointestinal System: No diarrhea or vomiting, decreased feeding
Urinary System: Daily wets five diapers, reduced urination
Female Genital System: Normal external genitalia
Musculoskeletal System: No deformities, no fractures
Neurologic System: No seizures, Tonic neck reflex, Moro reflex, the sucking reflex, and stepping reflex intact.
Hematologic Systems: No lymph nodes swelling, no easy bleeding after bruising

Functional Assessment (Including Activities of Daily Living)

Interpersonal Relationships: Family has support from relatives, lives in harmony with extended family members. Goes to church every Sunday and attends other social gatherings
Activity and Rest: Sleeps 10hours at night and takes two naps daytime
Economic status: Father is a tutor in a college; Mother is a business lady
Home Environment: Lives in a two-bedroomed house, well ventilated with adequate space for a playground
Coping/Stress Management: The parents share out their stresses with trusted friends, takes a walk when stressed for relaxing
Health Promotions: The parents do take the baby for clinic check-ups and immunizations, breastfeed the baby exclusively

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