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Department Of Pediatrics

PEDIATRIC HISTORY

General Data
This is a case of ___________________, ________ months/years old, Male/Female, Filipino, ___________ in religion, born
on _____________________, born in _____________________. Presently residing at ________________ , was admitted for the
______ time in this institution on _____________________ at around ______________ in the morning/afternoon/evening.

Informant: __________________________ Reliability: __________%

Chief Complaint: ________________________

History of Present Illness

Review of System
Skin: ( ) jaundice, ( ) pallor, ( ) erythema, ( ) wound lesions
HEENT ( ) headache ( ) dizziness ( ) lightheadedness ( ) Eye redness ( )Tearing ( ) Ear pain ( ) vertigo ( )Nasal
discharge ( ) Nosebleeds
Neck ( ) Swollen glands ( ) stiffness of neck
CNS: ( ) loss of consciousness, ( ) seizure, ( ) headache
Cardiovascular: ( ) chest pain, ( ) palpitation, ( ) easy fatigability
Chest and Lung: ( ) difficulty of breathing, ( ) cough, ( ) colds, ( ) hemoptysis
GIT: ( ) anorexia, ( ) nausea, ( ) vomiting, ( ) diarrhea, ( ) constipation, ( ) hematomesis, ( ) melana
GUT: ( ) dysuria, ( ) polyuria, ( ) oliguria, ( ) anuria, ( ) hematuria
Hema: ( ) bleeding tendencies, ( ) bleeding manifestation
M/S: ( ) limitation of movement, ( ) pain on movement

Maternal and Obstetrical History


The patient was born to a ____ year old G_P_ (_ _ _ _) mother who had regular/irregular prenatal check-up starting at ____
AOG and regular intake of multivitamin during the course of pregnancy. With/Without history of exposure to neither radiation nor
recalled taking any teratogenic drugs. With/Without history of maternal illness of ____________.

Birth History
After ____ hours of labor, which started on _____ in the morning/afternoon/evening to _______ in the
morning/afternoon/evening, the patient was born via Normal Spontaneous Vaginal Delivery/Cesarian Section (if CS, secondary to
______) attended at __________________ by traditional hilot/midwife/nurse/obstetrician with ________________ presentation.
No cord coiling, amniotic fluid was clear/thinly stained meconium, with/no spontaneous respiration, with poor/good cry, in/not in
cardio-respiratory distress, with a body weight of ____ kg/lb. Routine new born screening was done/not done and within the normal
limits. The mothers blood type is ____. After _____ hospital days, the patient was discharged.

Neonatal History
The patient has/ no history of neonatal jaundice at ___ day, had/had no history of neonatal cyanosis at _____ day was
noted. Meconium was passed out during/within 24 hours of life.

Nutritional History
The patient was/not exclusively breastfed/bottle-fed since birth then shifted to formula milk at ___ months old with a
delusion of ___:___. Patient had not/been taking vitamins of with a dose of ______. Presently the patient is fond of eating
________________.
Growth and Development
New Born: () Tonic neck reflex
() Pelvic high when supine
() Fisted hands, complete head lag
() Startle reflex

1 Month: () Pelvic now flat when supine


() Raises head slightly from prone position
() Smiles, diminishes activity when talked to

2 Months: () Head control up to 45 degrees from the prone position


() Hands no longer fisted
() Change in activity when spoken to
() Vocalizes (small throaty sound)

3 Months: () Moves head towards the sound


() Holds rattle temporary

5 Months: () Good head control


() Laughs loudly
() Reaches objects

6 Months: () Sits with support


() Rolls from supine to prone

7 Months: () Plays with rattle


() Recognizes familiar faces

8 Months: () Transfer objects from hand to hand


() Initiates hand movements

9 Months: () Sits well


() Holds bottle while feeding

10 Months: () Pulls to feet


() Understands gestures
() Uses thumb and index fingers to pick up objects

11 Months: () Stands with support


() Can talk 2 words with meaning

12 Months: () Stands alone and takes few steps


() Attempts to use spoon
() Cooperates in dressing
() Obeys commands and request

13 Months: () Walks alone well


() Build tower of two cubes
() Says four to five words

1 Year: () Creeps upstairs


() Builds a tower with three cubes
() Plays ball
() Has ten words
2 Year: () Runs well
() Can go up and down the stairs
() Combines two or three words in a sentence

2 Year: () Jumps
() Builds tower of six cubes

At the present, patient can ______________________________________________________________________________.


Patient is at/not par with age.

Immunization History
() BCG () Measles () Hep. B () MMR
() DPT () Rotavirus () OPV/ IPV () Hib B

Past Medical History/ Accidents


() Allergy Childhood illness:
() Asthma () Chickenpox
() Previous surgery: () Measles
() Previous Hospitalization:
() Congenital disease:

Family History
() Asthma () Heart disease
() Allergy () Cancer
() PTB () Thyroid disease
() Hypertension () Diabetes Mellitus

Environmental History
Patient lives with ___ other household members in a non/semi congested neighbourhood. Drinking water is from water
refilling station/faucet that is boiled for ___ minutes before consumption. Garbage is/not collected. There is/no standing water in
the immediate surroundings.

Physical Examination
General Survey
The patient is awake/asleep, conscious and coherent to time and place. Not/In cardio-respiratory with the following vital
signs of:
BP=___mmHg CR=___bpm RR=___cpm Temperature: ___0C

Anthropometric measurements: Wt.: ____ kg Ht: ____ cm BMI: ____ Z Score:____


HC= CC= AC=

Skin: Brown/White in complexion, () jaundice, () cyanosis, () rash, warm/cold to touch, good/poor skin turgor
HEENT: normocephalic/microcephalic/macrocephalic, () palpable head mass, flat/bulging/open/close anterior fontanel,
flat/bulging/open/close posterior fontanel, pink/pale palpebral conjunctiva, an/icteric sclera, with/without alar
flaring, with/without nasal discharge, with well formed pinna, wet/dry oral mucosa, with/no cervico
lymphadenopathy
C/L: a/symmetrical chest expansion, no/with retractions noted, clear breath sound, () crackles, () wheezes
th
CV: a/dynamic precordium, PMI is located at/not 4 ICS LMCL, regular/irregular rhythm, with/without murmur
Abdomen: flat/globular/distended, with/without visible veins, normoactive/hypoactive/hyperactive bowel sound, soft/firm
abdomen, with/without tenderness noted at _____________, liver is palpable ___cm below the right subcostal
margin, ___ liver span
Extremities: with/no gross deformities, pink/blue nailbeds, capillary refill of ___ sec, equal peripheral pulses
Neurological Examination:

CN I =
CN II =
CN III, IV, VI =
CN V =
CN VII =
CN VIII =
CN IX, X =
CN XI =
CN XII =

MOTOR SENSORY DEEP TENDON REFLEX

Prepared by: ______________________