Paediatric Clinical Examination – Child Development Example

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"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 historyChildhood illnesses: UTI and SVT 3 weeks ageSerious Accidents of Injuries: NoneSerious or Chronic Illnesses: NoneOperations of Hospitalizations: NoneImmunizationsBirth - HepB2 months - RV, DTaP, Hib, PCV, IPVAllergies: no known drug or food allergiesMedications: Propranolol 4.5mg/kg/day 8 hourlyDevelopmental 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 bubblesCurrent development: Attempts to roll overFamily HistoryMaternal Grandmother- Hypertensive with diabetes mellitus type IIMaternal Grandfather- Deceased at 65 years due to heart failurePaternal Grandmother- 60 years old with CardiomyopathyMaternal Grandfather- 56 years old Asthmatic on treatmentMother- 27yeras old and normal, no chronic illnessFather- Diabetic, and Obese on diabetic treatment and diet modificationAunt- NormalReview of SystemsGeneral: The child is healthy and happy, good sleep patterns decreased feeding and feverSkin: Slight rashes at the buttocks, no jaundice, and slight dehydrationHead: No trauma, normal head size.

Well distributed hairEyes: no discharge, no jaundice, no conjunctivitisEars: no dischargesNose and sinuses: Patent nostrils, no dischargesMouth and Throat: No teeth, no enlarged tonsils, no cleft palateNeck: No stiffness, no lymphadenopathyRespiratory System: Difficulty in breathingCardiovascular System: No cyanosis, no murmursGastrointestinal System: No diarrhea or vomiting, decreased feedingUrinary System: Daily wets five diapers, reduced urinationFemale Genital System: Normal external genitaliaMusculoskeletal System: No deformities, no fracturesNeurologic 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 bruisingFunctional 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 gatheringsActivity and Rest: Sleeps 10hours at night and takes two naps daytimeEconomic status: Father is a tutor in a college; Mother is a business ladyHome Environment: Lives in a two-bedroomed house, well ventilated with adequate space for a playgroundCoping/Stress Management: The parents share out their stresses with trusted friends, takes a walk when stressed for relaxingHealth Promotions: The parents do take the baby for clinic check-ups and immunizations, breastfeed the baby exclusively

References

Brugha, R., Marlais, M., & Abrahamson, E. (2013). Paediatric clinical examination. London: JP Medical.
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