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1 The history and examination

Objectives

When you have completed this unit you should be able to:

  • Introduce yourself to a mother and child.
  • Take a full history.
  • Perform a physical examination.
  • Make a clinical assessment.
  • Draw up a problem list.
  • Decide on a plan of action.
  • Write good clinical notes.

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Item Title
1-1 What are the steps in the general examination of a child?
1-2 Why is the introduction important?
1-3 How should you address a child?
1-4 Why is it important to listen to mothers?
1-5 Why is it important to keep the language simple?
1-6 What is the value of a referral letter?
1-7 What is the value of the Road-to-Health Card?
1-8 What basic information is needed?
1-9 Why are the age and gender important?
1-10 How should the child's size be recorded?
1-11 How should you measure the child's temperature?
1-12 How do you start taking a history?
1-13 Why is it important to obtain a good history?
1-14 Who should give the history?
1-15 What are the main parts of the history?
1-16 What is important to ask about in the present history?
1-17 What is important in the past history?
1-18 What is needed in the immunisation history?
1-19 Why may the social (home, family, school, economic) history be important?
1-20 What question in the social history should not be forgotten?
1-21 What special questions should be asked?
1-22 When can an interpreter help in taking a history?
1-23 Why is confidentiality important in history taking?
1-24 What can be learned by observing the mother and child during history taking?
1-25 What are the steps in the physical examination?
1-26 In what order should the steps of the examination be done?
1-27 What are the components of each step of the physical examination?
1-28 What is the most important component of the examination?
1-29 Where should the examination be done?
1-30 Should the child be undressed for the examination?
1-31 What is the best approach to the general and regional inspection?
1-32 How are the body systems examined?
1-33 What are important danger signs?
1-34 What are the early signs of dehydration?
1-35 What special examination may be needed?
1-36 What are the 10 common errors in the general examination of a child?
1-37 What special investigations are usually needed?
1-38 What additional investigations may be needed?
1-39 What is the assessment?
1-40 What is a problem list?
1-41 How do you make a diagnosis?
1-42 What is a plan of action?
1-43 What is the importance of good clinical notes?
1-44 How detailed should your notes be?
1-45 How should the notes of the first visit be laid out?
1-46 How should progress notes be written?
1-47 Should notes always be made in the Road-to-Health Card?
Case study 1
Case study 2
Case study 3
 
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