Pediatric Assessment Paper B245 NO

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School

Indiana University, Purdue University, Indianapolis *

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Course

245

Subject

Health Science

Date

Dec 6, 2023

Type

docx

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Uploaded by AgentOstrich3457

Your Name: __ _____ B245: Pediatric Health History Assessment Assignment Objectives The student will 1. Incorporate valid and reliable tools to assess the physical and functional status of a child. 2. Communicate effectively, respectfully, and compassionately with the child and parent. Directions To complete this assignment, you will need to collect a health history on a child between the ages of 2 and 8 years old. This assessment must be done in-person. This can be any child of your choosing, but you must have the verbal consent of the parent/guardian as well as the parent/guardian present during the encounter. The purpose of the exercise is for you, the student, to gain experience with obtaining a pediatric health history, it is not to diagnose . This paper will need to be typed. Use the form on the following pages to complete your assessment. The paper including all supporting documents: your typed paper, any supporting documents (growth chart, nutritional assessment, etc…), and a reference page must be compiled into one document and uploaded into Canvas by the date and time set by your faculty. Failure to turn in this assessment will result in a failure in B245. Child initials N.O . Age 7 Sex _ M Chief complaint of any acute or chronic disease processes: N/A History of present problem or illness : Symptom analysis: OLDCARTS ( Must complete. If there is not a current issue, use a previous symptom/complaint). O: Onset – When does this pain occur? Does the pain occur suddenly or gradually? 5 months ago. The baby teeth got loose. L: Location – Where do you feel the pain? Does the pain radiate or change its location? Pain in mouth. It was in the front lower teeth. D: Duration – How long doe the pain last? Is it constant or intermittent? How often does it occur and then last? If starts if I eat hard foods then stop when I do not chew on hard foods. C: Characteristics – Describe what the pain feels like Pt said pain feels warm like fire in mouth and sharp like pencil poke. A: Aggravating and Alleviating Factors – What makes the pain worse? What relieves the pain? Ice on mouth makes it better. Mouth wash makes it worse.

R: Related Symptoms – When you experience the pain, do you notice other symptoms at the same time? (palpitations, shortness of breath, sweating, rapid, irregular breathing, nausea, vomiting?) Did not want to eat certain foods like apples and would bleed if the teeth was moved around . T: Treatment by the Patient – How have you tried to relieve this pain? How effective have these measures been? The teeth got pulled out. It was the last baby teeth. S: Severity – How would you describe the intensity, strength or severity of the pain? Low -med intensity. 5/10 Family History : **Please include a Genogram in diagram form to illustrate the family history. This may be hand-drawn or created using a web-based tool. Criteria include: -Must contain 3 generations: self, siblings, parents, aunts/uncles and grandparents. -For each person, list the person’s age and any known medical conditions. -If there are no known diseases or conditions, write “ well” or “no diseases” for healthy individuals. -If an individual is deceased , the box is shaded, and the age at death and the cause of death are listed. Any unknown information is indicated such as ( cause of death: unknown). **You must include a key with your genogram to explain all the symbols that you use Mother’s Information Obstetric History – G/P/A: (after this child was born)

Gravida -# of times the mother has been pregnant (regardless of outcome) Parity -# of pregnancies reaching viable gestation (at least 24 weeks gestation) Abortus- # of pregnancies lost for any reason (include spontaneous and elective abortions) OVERALL Obstetric history= G-3/P-2/A-1 AFTER CHILD= G-0/P-0/A-0 Age with this pregnancy: 35 Prenatal care (yes or no)? Start and duration?: YES- difficult pregnancy Feb 2015- 0ctober 2015 Medications taken during pregnancy?( include over the counter and prescribed): No meds- just prenatal vitamins Exposures to high-risk behaviors such as alcohol, tobacco, x-rays, drugs, etc…?: No high risk behavior exposure Any complications of pregnancy: “The doctor had to sew the uterine line shut to keep the keep the baby in till due date” -mother. Weeks gestation at delivery: 40 weeks Type of delivery (C-section or vaginal? Type of anesthesia used?): C-section-General anesthesia Were there any complications in the delivery room?: No complications Child’s Health Information Weight and length of newborn: 3 kilograms and 48cm Breast fed or bottle (list formula type if bottle)? Feeding problems? Typical feeding schedule during infancy prior to introduction of solid foods? Breast feed and bottle for 6 months. After 6 months stopped breast feeding continued formula. Feeding schedule from birth every 2 hours following 3 months every 3hours and/or when baby cried. Length of hospitalization at birth and any complications: 3 days

Past Medical History: N/a Past Surgical History: N/a Hospitalizations (other than birth)? Include date and length of stay: N/A Fractures?: N/A Medications: Name of Drug Dosage/Frequency Reason for Taking Mucinex 5ml every 4 hours Runny nose/stuffy nose **Add additional rows as needed Allergies: Allergy To Type of Reaction Pollen Swollen and runny nose **Add additional rows as needed. Last physical exam: January 2023 Last dental exam (if applicable): December 2022 Last vision exam (if applicable): N/A Immunizations (are they up to date?) You do NOT need to include an immunization record. Up to date

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