177k views
1 vote
helen is creating a clinical description for a child that she is working with. what information would she typically include?

User Fazzolini
by
7.2k points

1 Answer

2 votes

Final answer:

A clinical description typically includes symptoms, medical history, and physical examination findings. It should be detailed and may also consider socio-environmental factors. This thorough documentation aids in understanding the child's condition and guiding treatment.

Step-by-step explanation:

When Helen is creating a clinical description for a child, she would typically include comprehensive details about the child's presenting symptoms, medical history, physical examination findings, and any preliminary diagnostic test results. For instance, if we consider the provided example of Hannah, a 15-month-old presenting with symptoms such as diminished appetite, sluggishness, confusion, irritability, vomiting, and light sensitivity, the clinical description might also document observations like abnormal reflexes, a stiff neck, and the environmental context of her symptoms. In another case with Olivia, the clinical description would note the excessive crying, irritability, sensitivity to light, unusual lethargy, vomiting, and physical findings such as swollen lymph nodes and abdominal swelling. By compiling diverse and related cases like Hannah, Olivia, and others such as Carli or Danielle, a pattern may emerge that could lead to a more directed hypothesis or diagnosis.

These descriptions must be detailed, including any relevant socio-environmental factors, which can be crucial for differential diagnosis as seen with Hannah experiencing potential infectious disease symptoms in Gambia. A clinical description serves as a foundation for health professionals to understand the child's condition in totality and aids in determining subsequent medical or psychological interventions. Collecting such data is akin to the detailed charting seen in the Post Partum Document or the drafting process for a paper in college, where organization and attention to concrete details play significant roles. Similarly, effective documentation aids in developing comprehensive treatment and support plans for the child's health and well-being.

User Khafaga
by
7.4k points
Welcome to QAmmunity.org, where you can ask questions and receive answers from other members of our community.