Paediatrics - Queensland Health - Queensland Government
Paediatrics - Queensland Health - Queensland Government
Paediatrics - Queensland Health - Queensland Government
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Paediatric presentation<br />
• Appetite and fluid intake / output during this illness<br />
-- try to be as precise as possible with quantities<br />
-- how many drinks / breastfeeds?<br />
-- how alert during feeds?<br />
-- how long between intake and vomit? / diarrhoea?<br />
-- how many wet nappies or times passed urine in preceding 24 hours?<br />
-- amount / type bowel movements<br />
• Treatment and / or medication given by carer during this illness?<br />
-- what, how much, when, how often, how effective?<br />
Past history<br />
Past medical and<br />
surgical history<br />
Family and social<br />
history<br />
548<br />
• Was delivery normal and were there any immediate neonatal problems?<br />
• Any problems with growth and development?<br />
• Significant illnesses in the past? What and when?<br />
• Hospital admissions? Why and when?<br />
• Operations or injuries? What and when?<br />
• Mothers alcohol history during pregnancy?<br />
• <strong>Health</strong> problems in the family - especially siblings and parents<br />
• Who looks after the child, what is the social situation?<br />
• Mental health problems in carers / child?<br />
• Household smokers?<br />
• Recent contacts or trips away<br />
• If medicines are given, will they be taken?<br />
Medications • Regular medicines (prescribed, herbal, bush medicines, over the counter)<br />
generic name(s), dose, frequency?<br />
• Are they taken correctly?<br />
• May need to ask about other medicine(s) in the home the child may have<br />
taken<br />
• See Medication reconciliation / Medication history checklist for more details<br />
Allergies • Adverse drug reactions:<br />
-- adverse reactions / allergies to medicines?<br />
-- attach “adverse drug reaction” sticker to medication chart if required<br />
• Allergens e.g. bee stings, tapes, sticking plaster, nuts:<br />
-- specific reaction e.g. skin reaction, bronchospasm<br />
-- is an Epi-pen® / medication used to treat the allergy?<br />
Immunisations • Check if up to date<br />
• Documented evidence of immunisation status should be obtained, follow<br />
up with opportunistic immunisation See Immunisation program<br />
Controlled copy V1.0<br />
Primary Clinical Care Manual 2011
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