MEDICAL FILE
Medical Document which includes:
I. GENERAL DATA
II. ANAMNESIS
III. PHYSICAL EXAMINATION
IV. INVESTIGATIONS, EVOLUTION, TREATMENT
V. EPICRISIS
I. GENERAL DATA
- child's full name, age (years, months and days), date of birth, sex;
- parents full name, occupation, place of employment, residence of the child and parents;
- date of admission, child health unit that sends the chil, the referring diagnosis.
II. The history will be taken from the mother, other carers or people who care for the child. Questions will be short, simple, formulated in a language to suit the cultural level of the carer.
Medical history includes:
reasons for hospital admission: the main signs and symptoms that led to request medical assistance.
medical history - all data concerning:
- timing and nature of disease onset;
- sequence of symptoms with the character, intensity and individual development;
- diet and medication child received (dose rate, route of administration, duration, - tolerance of drugs and their influence on the disease);
- hospital admissions for other diseases earlier and the disease in question;
- date of infection (infectious diseases)
family history (A.H.C.)
Mother:
- maternal age (older mother - risk factor for Down syndrome);
- number of pregnancies and births, induced or spontaneous abortions, at what age pregnancy occurred, premature births, twins, birth of dead fetuses (presumptive evidence of syphilis);
- acute illness during pregnancy (hepatitis, influenza, rubella, mumps), with a high potential for malformation (TORCH);
- chronic diseases (syphilis, T.B.C., diabetes, malaria);
Poisoning
- Exogenous (alcoholism, smoking);
- Endogenous (uremia in renal failure);
transfusion history;
nutrition during pregnancy;
physical or psychological trauma during pregnancy.
Father:
age (older father - risk factor for acondroplazie)
chronic diseases (T.B.C., syphilis)
poisoning (smoking, alcoholism)
Other children:
age and health;
dead children - the cause of death and at what age it occurred.
Medical history extends to all persons who came into contact with the child, if a suspicion of tuberculosis.
It will be investigated all family members and ancestors for hereditary diseases or congenital malformations.
Personal history:
Physiological:
Data in connection with childbirth:
- Gestational Age (GA),
- Place of birth (maternity or home births)
- Assistance at birth
- Natural / caesareanbirth
- Data about labor and expulsion,
- Presenter
- Mining obstetrical maneuvers.
Status at birth:
- If breathed and cried immediately after birth,
- Apgar score,
- Resuscitation maneuvers and their duration,
- Blue or white state of asphyxia,
- Deformities at birth,
- weight (Wb), height (Hb), head circumference (HCb)
Newborn period:
- when he received the first meal? (Ideally within the first 4-6 hours of life)
- Physiological phenomena during newborn period: physiological decrease in weight, physiological jaundice.
Nutrition:
- breast feding (human milk)
- bottle feeding / combined feeding
- weaning food: the age at which they received solid foodand how it has performed weaning.
Development of somatic weight and size at different ages,
The appearance of teeth.
Psycho-motor development with the main steps:
- When his eyes began to fix and follow objects around (1 month)
- The age at which the childheld his head (2 ½ - 3 months)
- When he appeared in this revival complex known person (2 ½ - 3 months)
- At what age stood upright with help (four months), and without help (6 months)
- When he stretched out his hand as he grabbed a toy and the coordinated movements (5 months)
- At what age stood at the bedside (7-8 months)
- Walked around the bed (9-10 months)
- Went independent (12 months)
- The first words (12 months).
Prevention of rickets: vitamin D - the route of administration, dosage, rhythm, how they were used to stimulate natural resources (sun, air, light).
Prenatal prophylaxis:
- Is given to pregnant women during the last trimester of pregnancy, 1000 - 2000 IU vitamin D / day orally, each day and 1-2 g calcium / day orally, 10 days / month.
Do not give vitamin D injection - risk of aortic stenosis in the fetus!
Postpartum prophylaxis:
- Begins in the 7th - the 10th day of life and given daily until the age of 24 months, 500-1000 IU vitamin D orally (Vigantol 1-2 drops per day, orally)
- No need to take calcium if the child receives at least 500 ml of milk per day
- Twins, premature and dystrophic: dose will be increased by 50-100% and will combine calcium (age 500mg/day/yearorally, 10 days / month)
- After two years of age, vitamin D may be administered per physician, during the months of the year with the letter R - 500 IU / day orally.
Immunizations schedule: to note all vaccination, revaccination and booster injections (time and dosage)
Compulsory national vaccination schedule:
Personal history:
Pathological
- Ill child - will be noted in order of their appearance, stating the duration, treatment, complications or sequelae occurred,
- Communicable diseases,
- Possible infectious contacts in the last three weeks
AND ENVIRONMENTAL CONDITIONS OF LIFE of the child:
The social environment: the material (income), cultural and educational family health;
Physical Environment:
- Microclimate: the hygiene room, a bed, clothing hygiene;
- Macroclimatic (natural causes hardening of the body): air, water, light and sun.
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