medrec

Putting Together a Medical History

Because you are inevitably going to be meeting with various health professionals, it is a timesaving and more accurate-than-your-memory idea to put together a report of your child's medical history. These can be typed and then Xeroxed and given to medical personnel. (It is also a good idea to have copies of any x-rays to be attached to this history as well as a complete set of medical records for your own files.) This is invaluable, especially if you are traveling and end up in the hospital. At our last unexpected hospital visit (in another state) the doctors studying our daughter's chest x-rays were very concerned about a soft tissue mass they saw on the chest-x-rays but were unable to identify. They were afraid it could be a tumor of some sort, but not having any of her previous x-rays they could not compare. Our daughter had to have a barium swallow done. The mass, as it turned out, was nothing more than her reconstructive gastric tube (a portion of the stomach that had been fashioned into a tube and connected to her esophagus). This hospital was used to seeing colon interpositions in a child with esophageal atresia, so the gastric tube, showing up as soft (stomach) tissue on the x-ray, was confusing to the doctors.

Winter, 1993

Re: (Child's name)

DOB: 10-02-87

To Whom It May Concern:

(Child's name) was born with an anorectal malformation and other associated defects (VATER association). She has required extensive surgical reconstrution, all performed at (hospital name), and has several ongoing medical problems. Her congenital defects included the following:

Past Surgeries

(Date of surgery) – Repair of tracheoesophageal fistula and descending loop colostomy. Dr. _______ performed the surgery.

(Date of surgery) – Cloaca repair by Pena technique. Dr. _______ performed the surgery.

(Date of surgery) – Colostomy closure. Dr. _____ performed the surgery.

(Date of surgery) – Esophagoscopy for trapped food. Dr. ______ performed the surgery.

(Date of surgery) – Untethering of spinal cord, lipoma removal, and spinal fusion at three levels. Dr(s)_________ performed the surgeries.

Medical Problems

Asthma – She was hospitalized (date) for asthma. She currently uses a Vanceril inhaler B.I.D. Occasionally she has required oral steroids to break an attack. Her asthma is currently managed by Dr. ____ (name, address, telephone number).
Gastroesophageal reflux – (Child's name) currently takes Prilosec 20mg daily and Reglan 5 mg B.I.D. The head of her bed is raised about 30º. On her last esophageal biopsy in 1/92, there was mild inflammation and no stricture. Because of an esophagela motility disorder and inflammatory changes, food occasionally gets caught. Usually this resolves spontaneously. This is managed by Dr. ___ (name, address, telephone).
Anorectal malformation – (Child's name) was born with a high imperforate anus. This was reconstructed during the Pena repair. As a result of this malformation, as well as some abnormal sacral innervation, she has occasional incontinence of stool and some smearing. For bowel regulation she uses Metamucil, 2 T. in 6 oz. of juice twice daily.
GU – She has a dysplastic left kidney with no function. The right kidneyis dysmorphic but functions well, and there is no reflux. She has infrequent lower tract infections and had one episode of pyelonephritis requiring hospitalization in (__date___). Her bladder empties well on ultrasound, and there is no evidence of a neurogenic bladder.

Current Medications

1. Prilosec 20 mg. daily
2. Reglan 5 mg. B.I.D.
3. Vanceril inhaler puffs B.I.D.
4. Metamucil 2 T. in juice daily
5. Nebulizer with Ventolin prn
6. Ventolin inhaler prn

Note: All pills are given crushed in applesauce.

Current Physicians

1. Pediatrician (name, address, telephone)
2. Surgeon (name, address, telephone)
3. Urologist (name, address, telephone)
4. Orthopedist (name, address, telephone)
5. Neurosurgeon (name, address, telephone)
6. Pulmonologist (name, address, telephone)
7. G.I. (name, address, telephone)

Note: She has no allergies

Sincerely,

(Parents' names and addresses/telephone numbers)