Fever Flashcards
Clinical case: A 5year old was brought to the clinic by his mum.
She complained that his body had been warm for 2 days
Take a focused history
1) GRIP
Greet - Good morning Sir/Ma,. good morning Ma
Rapport- how are you doing today
introduce- My name is “insert name” a candidate of the ongoing macn exam, and for the purpose of the exam, I have been asked to take a focus history from you.
Please May I proceed
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2) BIODATA (NASORATI)
Name: what is the child’s name
Age: how old Is the child
Sey• is this a male or female child
Occupation: what class is this child in? what do the parents do for a living
Religion: what religion do the parents practice
Tribe: what tribe are the parents
informant: what is your relationship to this child
Presenting complain: its states here that your child has been warm to touch for 2 days, is that right,?
ii. History of the presenting complain (DOCTOR)
_Duration: how long has this been happening?
Onset: did it start gradually or suddenly
it start suddenly or gradually
Character: did you confirm his temperature with a thermometer?
What were the values.
Has it been a low or high grade fever
Time: IS it worse in the morning or night time. Is it present all day or does it come and go
Other related: is this fever associated with chills and rigors
Related phenomenon: any nausea and vomiting, any weakness
CAUSES
1) malaria : does he sleep under mosquito treated net , or stay
near stagnant water. is he on any antimalaria medication
2) typhoid fever/ gastroenteritis : has he been having abdominal
pain. diarrhea and has he been vomiting
3) Malignancies: together with this fever, have you noticed weight loss , poor appetite , or yellowish discoloration of eyes and skin
4) URTI/ tonsillitis : has he been having cough, catarrh, vomiting and reduced appetite
5) UTI : any historv of painful urination. back pain . abnormal penile discharge
6) Otitis Media: any ear discharge,or has he been tugging at his ears
7) pneumonia: any history of chest pain, cough , fast breathing or difficulty in breathing
meningitis*
together with the fever any increased sensitivity to light, nausea , vomiting, neck pain or loss of consciousness
8) tuberculosis: has there been any cough. night sweats and weight loss
COMPLICATIONS
Complication
1) Cerebral malaria: any history of multiple seizures
2) Jaundice : any yellowish discoloration of the skin and eyes
3) Prostration: has he been too weak to stand
4 AKI : has there been any history of reduced urine output
5) Pulmonary edema: have you notice difficulty breathing or bluish a discoloration of his mouth
Care so far
what have you done so far for this condition
Have you taken any herbal concoction or medication
Have you visited any prayer house, pharmacy or hospital
Have you done any investigations
Past medical history
Has he had similar conditions in the past
Any history of chronic illness like asthma diabetes. sickle cell disease
Has he had any history of hospitalization.
blood transfusion or surgery in the past
PREGNANCY HISTORY
Was this pregnancy booked for antenatal
DId you have any infections, fever or rash during the pregnancy
Was the delivery at term
Was the delivery via vaginal caesarean section… if yes, why?
It vaginal was it spontaneous or induced
Did he cry immediately after birth
How long did he stay in the hospital before discharge
NUTRITIONAL HISTORY
Did you Give your child breastmilk only for the first 6 month
Does he eat what the family eats
Frequency - how often does he eat in a day
Adequacy - does he eat and ask for more
Density - does his meal contain all the classes of food in the right proportion
Do you think your child is growing
IMMUNIZATION HISTORY
immunization history
Has he received all his vaccination for his age
Can I see your child’s vaccination card was there any reaction to vaccine
DEVELOPMENTAL HISTORY
Developmental history
when did he start sitting without support crawing/ standing
How is his performance at school
What is his relationship with other children Like
DRUG HISTORY
Is he on any long term medication
Is he on any current medication
Does he have any drug allergy
REVIEW OF SYSTEM
So Ma, just to be sure I didn’t miss any symptoms I would
like to ask you some questions….just say yes or no
UNS: any seizures, headaches, double vIsIon
Endocrine: any neck swelling ,excessive sweating, unexplained weight loss or weight gain
Respiratory : an chest pain . Fast breathing, difficult breathing
CVS: any chest pain, palpitations, fast heartbeat, bluish discoloration of his lips
Digestive: any abdominal pain, diarrhea or constipation.
GUS: any increased frequency of urinating, painful urinating
MSS: any joint pain, joint stiffness, bone pain, difficulty walking
