Pediatric History Taking

Paediatric History Taking Site Radiation Character Severity Time questions Onset Episodic or continuous No. of episodes Duration Progression Previous episodes Context Anything changed around that time Aggravating Relieving Impact on life Systems review System Questions Headaches? Head Blurred vision Eyes Double vision Nose bleeds Nose Does anything other than sorts come out of their nose? Does the child snore loudly Does the child have trouble swallowing foods and liquids? Mouth and throat Does the child brush their teeth after eating? Have you noticed any lumps in the child’s neck? If so, were the sore? Neck Stable in size growing -> lymphadenopathy Does the child have trouble keeping their back straight? Torticollis Does the child get more short of breath than his or her friends when playing sport? Does the child get wheezy? Chest Does the child have problems with coughing? Does your child cough anything up? Does your child often vomit or get tummy pain? Abdomen Has your child had problems with runny poo when going to the toilet? Does your child sometimes find it difficult to poo? Does your child have pain when passing urine? Has there ever been blood in the child’s urine? For girls: Vaginal discharge? At what age did your periods begin? Genitourinary Tell me about your periods. Are they painful? Do they happen regularly? Is there much blood? Are you sexually active? Has your child been drinking more water lately? Endocrine Does your child urinate at night? Has your child had more or less energy lately? Has your child had problems with dizziness? Tell me what it feels like Neurological Has your child ever had a fit? Have you noticed weakness in your child’s arm? Has your child had any rashes on the skin? Skin Are they itchy? Does your child get may bruises? Past medical history Conditions Previous surgery Trauma Hospitalisation Allergy Menstrual history Medications Reason Dose Frequency Adherence Immunisations Up to date Allergies Past surgical history Family history Any unexplained premature deaths in the family? Antenatal and birth history Mum factors Maternal age Number of previous pregnancies Maternal health in pregnancy – complications Planned vs unplanned Natural, IVF Labour and delivery Gestational age at delivery Presentation -> cephalic, breech presentation Rupture of membranes History of fetal stress Type of delivery Spontaneous Interventions Use of forceps, anaesthesia Neonatal period Apgar score Birth weight, head circumference, length Health concerns at birth Resp distress Oxygen therapy Hyperbilirubinemia Anaemia Birth injuries feeding concerns Congenital anomalies Age at discharge Was resus needed ? Admission to NICU Developmental history and milestones Smiling – 6 weeks Sit – 5 to 7 months Crawl – 9 months First word – 12 months Speech – 2-word phrase – 24 months Regression Has there been a loss of any skills Current level of devel – what can he or she do? Hearing or vision Behavioural issues that are not age appropriate Weight and height Feeding history Breast or formula How much/how often How much cow’s milk do they consume When did they transition to solid foods Do you eat together? Psychosocial history – BEST CARE BEhavioural history: Tempers Sleep disturbances Phobias Toileting problems Screening of development and social interactions: School performance Vision Hearing Speech Gross and motor function Typical day Living conditions Social history Child’s habits regarding physical activity Food and diet Dental care practices Safety Use of bike helmets Seatbelts Coping with hospitalisation and/or disease Access to health acre Family living in a remote area Has transport available Relationship with others How family members get along with each other? Extended family support? Any alternative care arrangements? Who are the primary carers? Is the child in foster care? Does the child spend time between family members? Effect of illness on the child and the family How limitations in physical or cognitive, emotional and social functioning and the dependence on services impact on the child, siblings or parents Ask if they have any other concerns. Fever DDx Condition Features Dysuria Flank pain Urgency Urine colour Blood in urine Number of nappies UTI Frequency Abdominal pain Irritability Poor feeding Diarrhoea Lethargy Sensory changes Rash Inflamed/red eyes/itchy eyes/teary eyes Swollen lymph nodes Edema especially in the hands and feet Red, bumpy and swollen tongue Joint pain Kawasaki Nausea Vomit Diarrhoea Abdominal pain Tachycardia Cyanosis Photophobia Phonophobia Neck pain/neck stiffness Back pain Ear pain Building fontanelles Nausea Meningitis Vomit Altered conscious state Diarrhoea Poor feeding Lethargy or drowsiness Seizures Recent ear infections, recent sinus infections Seizures – more common to appear in here than in meningitis Unusual behaviour Confusion Personality change Encephalitis Emotional liability Bradycardia Hypertension Abnormal movements or sensations Productive cough Chest pain Sore throat Voice changes Difficulty breathing Increased Pneumonia work of breathing Nasal flaring Apnoeic episodes Recessions Tracheal tug (have you seen the trachea being pull downwards as the child wants to take a breath in?) Tachypnoea at rest How long did it last for? One side or both sides? Which limps were involved? Drooling Eye rolling Febrile seizures -> eyes rolled back -> only the white parts are visible Did the child change colour? Loss of consciousness Shaking of the body limps Note start and end times Did you take a video of the child? Otalgia Irritability Fever Acute otitis media Loss of appetite Vomit Lethargy cochlear implant Immunocompromised Severe e ar pain Esp at night Otitis externa Otorrhoea Itching Hearing loss Jaw pain Fever Sore throat Tonsillitis and pharyngitis Dysphagia Lymph nodes Red and swollen tongue Exudate DDx for Shortness of breath/difficulty breathing Condition Features Barking cough Stridor Voice hoarseness Low grade fever Croup Increased work of breathing Sore throat Lethargy or agitation Allergies Eczema features Asthma Increased respiratory effort Features of respiratory distress Wheeze Mild fever Persistent dry cough Apnoeic episodes Bronchiolitis Coryzal symptoms Runny nose, sneezing, itchy and watery eyes, increased mucus production Cyanosis Features of respiratory distress Fever Productive cough Chest pain Difficulty breathing Pneumonia Fatigue Loss of appetite Abdominal pain Tachypnoea Stridor High pitched sound Apnoea Cyanosis Laryngomalacia GERD Spitting vomit Aspiration Feeding difficulties Sore throat Fever Cough Coryzal symptoms Epiglottitis and pharyngitis Inflamed throat Enlarged tonsils Exudates Diarrhoea DDx for Abdominal Pain Condition Features Persisting right lower abdominal pain Guarding Abdominal distention Rebound tenderness Tenderness on percussion Acute Appendicitis Weight loss Preference for positions Do they prefer to lay flat and still ? Do they have difficulty walking? Dehydration Sunken eyes Dry skin Dry mouth Changes to heart rate Changes to breathing Sunken fontanelle Sunken eyes Warm or cool to feel Urine output Weight loss Pale or mottled Gastroenteritis Thirst Tears Alert, irritable, lethargic What colour is it? Is there blood? Do they seem to have lost any weight? Fluid and food intake Diarrhoea Vomit Irritability Loss of consciousness Decreased level of activity Pain Colicky, sudden and intermittent Jelly-like blood-stained stools Did you feel their abdomen? Could you feel a mass? Intussusception Nausea Vomit Restlessness Lethargy Irritable Pale Feeding Bilous vomit Malrotation and volvulus Abdominal pain Tenderness -> peritonitis or ischemic bowel DDx for diarrhoea Condition Features Frequency Colour Fever Nausea Vomit Gastroenteritis Colour and contents Urine output Back pain Features of dehydration Fluid and food intake Happens 30 minutes to 2 hours after food Worse with larger quantities Abdominal pain or cramping Lactose intolerance May be primary or secondary (postgastroenteritis) Bloating Flatulence Diarrhoea Nausea Vomit Worsen after eating certain types of food Has the child ever tried a gluten free diet Chronic diarrhoea Nausea or vomit Pale stools, bulky or oily Coeliac Disease Poor weight gain, weight loss Delayed feature of puberty or short stature Mouth ulcers Family history Fever Behaviour – irritability, fatigue Chronic cough Wheeze Nasal polyps Sinusitis Phlegm production Difficulty clearing mucus Cystic Fibrosis Recurrent PNU or lung infections Exercise intolerance Steatorrhea – bulky, greasy pale stools that are hard to flush. History of meconium ileus at birth? Have they been diagnosed with pancreatic insufficiency or needed enzyme supplements Dehydration Salty taste Intestinal surgery History of meconium ileus Chronic diarrhoea Vomit Short bowel syndrome Bloating Poor weight gain, failure to thrive or growth delays Parental nutrition or enteral feeds Nutritional deficiencies Vitamin or electrolyte supplementation Blood or mucus Urgency Tenesmus Nocturnal stools Abdominal pain Constipation Perianal symptoms -> fissures, fistulas, skin tags IBD Nutritional deficiencies Joint pain, skin rashes, eye symptoms, oral ulcers or dental enamel defects Fever Fatigue Weight loss Anaemia Edema Persistent, progressive or relapsing Poor performance Irritability, anxiety and emotional liability Weight loss Increase appetite Rapid linear growth or signs of advanced bone age Heat intolerance, excessive sweating Palpitations Hyperthyroidism Tachycardia HTN Nausea, vomit and diarrhoea Bludging eyes, lid lag Hx goitre Menstrual irregularities Fatigue, weak or lethargic Dizziness Poor stress tolerance Addison’s disease Weight loss or loss of appetite Dehydration Skin darkening Recurrent infections Vomit Diarrhoea Abdominal pain Bloating Allergies Failure to thrive Cow protein Wheeze Nasal congestion Cough Eczema, urticaria or angioedema Baked muffin – did they tolerate that fine? History of asthma, eczema, hay fever or food allergies Hirschsprung associated enterocolitis Neurological motility disorders or medications Seizure history features Before the event Aura/warning sign What was the child doing? Triggers Recently unwell During event Witnessed By whom Was it recorded Types of movement Can you describe what happened? Types of movement Duration Consciousness Eye deviation, head turning Incontinence Tongue bitting Especially lateral Cyanosis Drooling Apnoea Did they fall or injure themselves Loss of consciousness After the event Postictal phase Confusion, sleepiness, weakness How long did it take for the child to return to baseline? Any neurological deficits afterwards? E.g. Todd’s paresis Was emergency treatment needed Midazolam Previous episodes Differentials Febrile seizures Afebrile seizures Infantile spasms (west syndrome_ Clusters of spams, developmental regression, hypsarrhythmia on EEG Violent flexor spasms of the head, trunk and limbs followed by extension for the arms. Social interaction often deteriorates Idiopathic epilepsy syndromes Normal development Childhood absence epilepsy Meningitis/encephalitis Momentary Sepsis unresponsive Hypoglycaemia, hyponatremia, hypocalcaemia stare with motor Genetic epilepsy syndromes arrest Dravet syndrome May tw Drug poisoning/infection itch their eyelids Child has no recall except realising that they may have missed something and may look puzzled. LennoxGastaut syndrome Mixed seizure types Mostly atonic, atypical (subtle) absence and tonic seizures in sleep. Stridor Condition Features Infancy onset Worse when supine Laryngomalacia May improve when prone Noisy breathing since birth Weak cry Feeding issues Vocal Cord Paralysis Aspiration History of birth trauma or thoracic surgery Biphasic stridor if bilateral History of prolonged intubation Biphasic stridor Subglottic stenosis Recurrent croup episodes Poor weight gain Barking cough Hoarseness Croup Fever Worse at night Difficulty breathing Sudden onset of high fever Drooling Dysphagia Epiglottitis Muffled voice Sitting forward -> tripod position Toxic appearance No cough High fever Toxic appearance Recent viral URTI Bacterial Tracheitis Rapid progression Thick secretions Productive cough Biphasic stridor Allergen Rapid onset swelling Urticaria Anaphylaxis Wheeze Hypotension Inspiratory stridor from airway edema Trauma Wheeze DDx Condition Features Less than 5 Triggered by an URTI Viral induced wheeze No symptoms between episodes Often resolves by 6 May have frequent episodes in winter Recurrent wheeze Night cough – dry cough Exercise intolerance Asthma Family history of asthma, eczema or hay fever Personal history of the above Good response to bronchodilators May worsen early morning or at night Sudden wheeze of cough onset History of choking episodes Foreign body aspiration or playing with small objects Afebrile between episodes Coryzal symptoms Runny nose, mild fever, itchy and watery eyes, irritability Progressive cough and wheeze Feeding issues Bronchiolitis Increase WOB Apnoea No interval symptoms Unlike asthma -> symptoms are continuous during illness Peak in Australia -> autumn – winter Persistent wheeze Chronic cough Recurrent chest infections Steatorrhea Cystic fibrosis Poor weight gain Nasal polyps Clubbing Family history or positive newborn screening Wheeze associated with feeding or lying flat History of vomiting, regurgitation or arching M GERD a y have a chronic cough or hoarseness Poor weight gain or feeding issues Food allergy How soon after Amount of food How long does it last for Can they tolerate baked cakes For egg allergy Cardio, GIT, Rep and dermatological features Swollen lips Swollen tongue Questions for ear pain Fever Crying Irritability Vomit Loss of appetite Cochlear implant Immunocompromise DDx for Constipation Defined as the presence of at least two of: Infrequent passage Less than 3 per week Large and hard Rabbit dropping stools Overflow soiling Ask if there is Staining Pain Bleeding Abdominal pain Reduced appetite Change in fluid in take or diet Does the child often hold it on purpose e.g. to continue playing or avoid distance or afraid of going to the toilet at school Weight changes Condition Features Withholding stools due to fear or previous painful defecation Pool toilet training habits E.g. ignoring the urge to go Low fibre diet Functional Inadequate water intake Lack of physical activity Stress of anxiety Toilet training issues Changes in routine Failure to mass meconium within the first 24 hours Abdominal distension Bilious vomit HD ` Poor feeding Failure to thrive Feeding issues Abdominal distension Failure to pass meconium Bilious vomiting If passed stools >, are they lose, yellow, floating and hard to flush Prolonged jaundice Chronic cough Meconium ileus -> Cystic Fibrosis Respiratory infections Wheeze Nasal polyps From chronic sinusitis Digital clubbing Vision Bone health Immunity Bruises Spinal Cord Abnormalities SCI Motor deficits Spinal cord compression Sensory deficits Tumor or disk herniation Autonomic dysfunction MS Back pain T Spasticity ran Back pain sverse myelitis Delayed motor milestones Early hand preference Asymmetric patterns Cerebral palsy Poor coordination Involuntary movements Ataxia Fatigue Weight gain Constipation Hypothyroidism Dry skin Voice hoarseness Sleepiness Bradycardia Opioids Medications Anticholinergics Iron supplements Chronic diarrhoea Abdominal distension Failure to thrive Coeliac disease Vomiting Delay in puberty Constipation Less common Jaundice Colour of stools and urine -> dark urine and pale stools Conjugated -> biliary obstruction E.g. biliary atresia If normal -> unconjugated Feeding history Breast milk Formula milk Birth history Prematurity history Physiological jaundice Antenatal history Medical infections CMV, hepatitis B, rubella Maternal blood incompatibility Haemolytic anaemia Family history Associated features Fever, lethargy Sepsis Vomiting Hepatitis, obstruction Abdominal distension Hepatitis, obstruction Itchy skin Cholestasis Bleeding/bruising Coagulopathy from liver dysfunction Developmental delays Hypothyroidism, metabolic disorders Limp pain Past medical history Previous history Neonatal ICU Blood transfusions Social history Exposure to hepatitis A from contaminated water Child with a Limb History Duration Less than 48 hours -> trauma, infection Subacute -> days to weeks -> transient synovitis, Perthes disease Chronic -> more than 1 week -> developmental dysplasia, malignancy, neuromus cular disorders Nature of pain Antalgic gait (shortened stance phase) ? pain-related (e.g. fracture, infection) Trendelenburg gait ? hip weakness (e.g. Perthes, SUFE) High-stepping gait ? neuropathy (e.g. cerebral palsy) Circumduction gait ? limb-length discrepancy, joint stiffness Red flag features Night pain or pain when walking Malignancy, infection Inability to weight bear Fracture, septic arthritis Fever, weight loss and fatigue Infection, malignancy, rheumatologic disease Rash, bruising, petechiae Vasculitis, HSP, leukemia Trauma history Infection history Recent viral illness Transient synovitis Skin infections, sore throat Reactive arthritis Systemic symptoms Osteomyelitis, septic arthritis Past medical and family history Developmental delay -> neuromuscular disorders Bleeding disorders -> hemarthrosis Sickle cell disease -> vaso -occlusive crisis Autoimmune conditions -> juvenile idiopathic arthritis Haematuria Previous history How much is there and what colour is it? Symptoms of urinary infection Dysuria F requency P ain F ever Cloudy urine Smell Bed wetting Discharge Systemic features Fatigue Oedema Rash Arthralgia Coryza Recent surgery or trauma History of a bleeding or an immunodeficiency disorder Medications NSAIDs, rifampicin, metronidazole, nitrofurantoin, cyclophosphamide Food intake Beetroot and berries -> urine -> dark pink or red Exercise DDx Polyuria and polydipsia Onset Sudden -> DM, central diabetes, DI Gradual -> nephrogenic DI, psychogenic, renal tubular Since birth -> congenital nephrogenic DI, renal dysplasia Fluid intake Volume Frequency Nocturnal drinking Craving cold water or ice Psychogenic Nocturnal thirst -> DI Urine output Frequency Volume Compare with siblings or diaper changes or baseline Nocturia -> DI, poorly controlled diabetes Toilet training Associated features Weight loss and fatigue -> DM Failure to thrive -> DI, renal tubular disorders Constipation and irritability -> hypernatremia from DI Vomit, dehydration -> renal tubular acidosis, salt wasting Seizures or altered consciousness -> severe hypernatremia or hypoglycaemia Headache or visual changes -> pituitary adenoma Photophobia -> cystinosis Past medical history Developmental delay -> congenital syndromes Feeding history (infants) Improper dilution -> solute diuresis Excessive crying relived by water -> polydipsia Medication history Diuretics, lithium, corticosteroids Recent IV fluids or mannitol Social history Access to water -> e.g. school restriction Behavioural patterns -> e.g. compulsive drinking Speech delay When did this begin? Age of first word Age of first babbling Age of saying mama/dada Compare with norms By 12 months -> babbling and gestures By 18 months -> 10 to 50 words By 2 years -> 2-word phrases By 3 years -> simple sentences Hearing and responsiveness Does the child respond to their name? Do they respond to sounds? Do they respond to verbal commands? Is there a history of ear infections? Did they do a newborn hearing test? What were the results? Cognitive and social development Play behaviour -> pretend play, joint attention, turn taking Social interactions Eye contact Pointing Sharing interest Comprehension Follow commands Understand questions Multilingual households May effect expressive language but not comprehension Cause Clues in History Hearing impairment Poor response to sound, frequent ear infections, failed hearing screen Autism Spectrum Disorder Poor eye contact, lack of gestures, regression, repetitive behaviours Developmental Language Disorder Isolated language delay, normal cognition and motor development Global Developmental Delay Delays in motor, cognitive, and social milestones Intellectual Disability Poor problem-solving, delayed milestones across domains Cerebral Palsy Motor delay, feeding difficulties, spasticity Childhood Apraxia of Speech Inconsistent errors, difficulty imitating sounds, poor intelligibility Environmental deprivation Low stimulation, neglect, excessive screen time Multilingual exposure May appear delayed in expressive language but comprehension is usually intact Gross motor delay When did it begin? Ask about key milestones Head control -> 3 months Rolling -> 4 to 6 months Sitting -> 6 to 8 months Crawling -> 9 months Walking -> 12 to 18 months Neurological history Muscle tone -> floppy ( hypotnia ) or stiff (hypertonia) Movement quality Smooth vs jerky, symmetrical vs asymmetrical Fatigability Associated features Cerebral palsy: spasticity , abnormal tone, delayed milestones, perinatal insults Muscular dystrophy: progressive weakness, using hands to walk up (Gower’s sign) , enlargement of the calf muscles ( calf pseudohypertrophy ) Spinal muscular atrophy: floppy infant, tongue fasciculations, absent reflexes Genetic syndromes e.g. Down syndrome and Fragile X syndrome : developmental history, speech delay, dysmorphic features, joint laxity , poor balance/coordination ASD: repetitive behaviours, poor eye contact, deficits in social interactions. Hypothyroidism: constipation, lethargy Medical history and family history Congenital anomalies Spina bifida Hydrocephalus Previous infections Meningitis Encephalitis Metabolic disorders Vision or hearing concerns History for Autism Eye contact Limited or absent Attention Gestures Wave Nodding Using hands to communicate Language development Delayed speech or regression? Echolalia -> repeating phrases? Pronoun reversal -> e.g. saying you instead of I Stereotypes Hand flapping, rocking, spinning Routines -> distresses with changed, rigid rituals Fixated interests -> intense focus on specific topics or objects Sensory sensitivities -> aversion to sounds textures, lights. Developmental Milestone delays Progression Play behaviour DDx Global developmental delay Delay in all of motor, language and cognitive areas Usually in children under 5 ADHD Inattention Hyperactivity Impulsivity Social skills Usually intact Hearing impairment Language impairment Isolated speech delay Normal social interactions and play Global developmental delay history Ask about delays in two or more areas: Gross motor -> sitting or walking Fine motor -> grasping, drawing Speech and language Cognitive/problem solving Social and emotional Regression or plateau Loss of any previously acquired skills Neurodegenerative or metabolic disorder Skills that plateau Static encephalopathy -> cerebral palsy P re natal history Maternal infections -> e.g. CMV, rubella Substance use Advanced maternal age Consanguinity Antenatal scans Structural anomalies, IUGR Perinatal history Postnatal history Feeding issues, vomit, failure to throve Recurrent infections -> otitis media, pneumonia Head trauma or prolonged hospitalisations Family history Associated symptoms Seizures Vision or hearing concerns Dysmorphic features Behavioural issues -> e.g. hyperactivity, poor social engagement Disruptive Behaviours Behavioural descriptions Specific behaviours Defiance Tantrums Lying Stealing Rule breaking Frequency, durnation and intensity Setting: home, school, public Triggers and antecedents Response to discipline or correction Onset and course Age of onset Gradual vs sudden Progression or escalation over time Any regression or change in baseline behaviour Functional impact Academic performance Peer relationship Family dynamics Safety concerns Developmental or medical history Family and social history Category Examples Neurodevelopmental ADHD, autism spectrum disorder Key Features Impulsivity, poor social skills, sensory sensitivities Behavioral disorders Oppositional defiant disorder (ODD), conduct disorder (CD) Defiance, aggression, rule-breaking, lack of remorse Psychiatric Anxiety, depression, OCD Emotional dysregulation, avoidance, irritability, meltdowns Learning disorders Dyslexia, dyscalculia Frustration with tasks, avoidance, acting out in academic settings Environmental Neglect, abuse, inconsistent parenting Poor boundaries, reactive aggression, attachment issues Medical/neurological Sleep disorders, epilepsy, sensory processing disorder Fatigue, irritability, sensory overload DDx for low weight gain Was this planned or unplanned? Over what period has this weight been lost? Condition Features Weight loss Increased thirst Increased urination Urination at night Diabetes Where they previously toilet trained Increased breathing Changes to the smell of the breath Lethargy Bulging eyes Changes to vision Tremors/shaking Heat intolerance Neck lump Hyperthyroidism Increased heart rate High blood pressure Changes to appetite Changes to bowel habits Menstural cycle problems Diarrhoea or constipation or alternating bowel habits Muscle weakness Vision changes Bone weakness Poor immunity – poor infections Increased bruising Coeliac disease Increased fatigue Mouth ulcers Pallor Short stature Puberty issues? Diet – any foods seem to trigger it Changes to appetite c Developmental or congenital abnormalities Shortness of breath Cyanosis Cough Chronic respiratory or cardiac diseases Fever Pallor Cool peripheries Heart rate Dizziness Blood in stools Cow Milk Protein Intolerance Mother’s diet What is the baby eating? Other DDx Poor intake Lots of exercise DDx for Chronic Abdominal Pain Condition Features Non-specific features No organic cause Functional Abdominal Pain School stress or anxiety or family problems Are they worried about the pain and seek frequent reassurance? Is it interfering with school attendance ASK ABOUT THIS IN EVERY HISOTRY Pain Altered bowel movements Stress Bloating Irritable Bowel syndrome Flatulence Mucus in stools Abdominal distention Dyspepsia Heart burn Functional dyspepsia Upper abdominal discomfort without a structure abnormality Episodic pain Nausea Pallor Vomiting Flushing Abdominal migraines Appetite changes Anorexia or weight loss Photophobia Headache IS THIS CHILD COMPLETELY WELL BETWEEN EPISODES ASK ABOUT THIS FOR ANY HX WHERE THE SYMPTOMS ARE EPISODIC Infrequent bowel movements Hard stools Constipation Palpable faecal mass Is there blood, mucus or green things in the stools? Are the stools hard to flush? Epigastric pain Heart burn Regurgitation Difficulty swallowing GORD Pain on swallowing Coughing Chocking Feeding aversion Wheeze Chronic diarrhoea Bloating Anaemia Joint pain Weight loss Steatorrhea Flank pain IBD Muscle weakness Fatigue Vision issues Urinary symptoms Vomit FLATTERTING GROWTH OR PUBERTY Arthralgia Skin symptoms Fever Nausea Vomit Diarrhoea Fatigue Mesenteric adenitis Reduce appetite Central or right lower quadrant Can mimic appendicitis Recent respiratory infections Tonsillitis Does it come after eating? Is it relieved by eating? Nausea or vomit Epigastric pain Peptic ulcer Bloating Loss of appetite Fatigue Blood in stools – melena Recent infections Epigastric pain Bruises Decreased urine output Difficulty breathing Dizziness Pancreatitis Weight loss Fever Chest pain Diarrhoea or steatorrhea Tachycardia Jaundice