pediatric medical record, Pediatric Medical Record

The Pediatric Medical Record includes:

Family - Hereditary History

  • Father – Mother - siblings - husband/wife - children
  • Other Relatives - twins

    • Perinatal Health Record

  • Place of birth - date
  • Mother's age -baby order
  • Maternal health during pregnancy (gestational diabetes - infections - medications - placenta abnormalities - etc.)
  • Gestational age (weeks)
  • Childbirth: (premature - prolonged - caesarean - embryo) Neonatal: birth weight - length - head circumference - Apgar score
  • Neonatal problems (respiratory distress - cyanosis - seizures - jaundice - vomiting etc)

    • Nutrition - Medicines

  • Breastfeeding (beginning - end) Artificial milk
  • Cream - fruit - soup - meat -fish - egg - others
  • Vitamins
  • Medicines

    • Ψυχοκινητική Ανάπτυξη

  • Στήριξη κεφαλής - σύλληψη
  • Παρακολουθεί - χαμογελά
  • Κάθεται - στέκεται
  • Βάδιση - ομιλία
  • Έλεγχος σφιγκτήρων (ημέρα/νύκτα)

    • Εμβολιασμοί

  • Διφθερίτιδας/τετάνου/κοκκύτου (DΤP) Ιλαράς/παρωτίτιτιδας/ερυθράς (MMR) Πολιομυελίτιδας (IPV)
  • Αιμοφίλου ινφλουέντζας (HIB)
  • Ηπατίτιδας Β - Ηπατίτιδας Α
  • Mantoux - Εμβόλιο BCG
  • Άλλα (μηνιγγιτιδοκόκκου, πνευμόνιο- κόκκου, γρίπης, ανεμεβλογιάς κ.ά)

    • Previous Health Status

  • Childhood diseases
  • Imports to hospital - operations
  • Injuries-bruises
  • Drug Use
  • Allergies

    • Personal and Social History

  • Place of birth - accomodation
  • Religion - Education -Employment
  • Family life-problems
  • Hobbies - pets
  • Harmful individual habits
  • Exposure to harmful environmental factors

    • Personal Commemorative (by systems)

  • general
  • skin
  • head - cervix
  • eyes
  • ears-nose-mouth-pharynx
  • breasts
  • respiratory
  • cardiovascular
  • digestive tract
  • haematopoietic - lymph nodes
  • urinary tract
  • overhead
  • nervous
  • mental functions

    • Objective Examination

  • BODY EVALUATION:
    • Weight– height - BMI Head circumference
  • VITAL POINTS:
    • Temperature -heartbeats-breaths
  • OVERALL IMPRESSION:
    • Shaping - appearance - nourishment - height - weight - teething - teenage stage
  • PSYCHODIANOTIVE SITUATION
  • SKIN:
    • Hue- turgidity - hair loss - rashes etc
  • HEAD:
    • Eyes - Nose - ears - mouth - pharynx
  • NECKING:
    • Movements -thyroid - trachea - lymph nodes - big vessels

    Objective Examination II

  • BODY:
  • UPPER LIMBS:
    • Hands - palms - fingers - nails - muscle strength - joints - vessels
  • LEGS:
    • Edge - soles - fingers - claws - hammers - gastropneumonia - muscle strength - joints - vessels
  • BREASTS
  • LYMPH NODES
    • Cervical - supergy - axillary - inguinal - others
  • RESPIRATORY:
    • Overview - attack - palpation - hearing

    Objective Examination III

  • CARDIOVASCULAR:
    • Heart: thrust-tones-blasts-roots Vessels: heartbeats - blastings
  • ABDOMEN
    • Overview - attack - palpation - hearing Liver - spleen - kidney Finger examination
  • UROPIOGENEANT
  • UROPIOGENEAN MUSCULATION:
    • Muscle tone - muscle power joints
  • NERVOUS SYSTEM:
    • Consciousness - Communication - Orientation - Attitude - Buddhism Sensibility - mobility - Brain conjugations - cerebellum
     

    Expression of Interest

     
    Info
    Font size
    Contrast