pediatrics history taking

1. 1. PEDIATRICS HISTORY TAKING(MY PROTOCOL)I. PATIENT’S PROFILEII. PRESENTING

COMPLAINTSIII. HISTORY OF PRESENT ILLNESSIV. BIRTH HISTORYV. FEEDING HISTORYVI.
IMMUNIZATIONVII. DEVELOPMENTAL HISTORYVIII. PAST HISTORYIX. PERSONAL HISTORYX.
DRUG HISTORYXI. FAMILY HISTORYXII. SOCIO-ECONOMIC HISTORYI. PATIENT’S PROFILE1)
Name2) Age (Date of Birth)3) Sex4) Address of parents5) Date of admissionII. PRESENTING
COMPLAINTS(Use parents’ own words + chronological order)III. HISTORY OF PRESENT
ILLNESS1) Enquire as to when patient was last entirely well?2) Presenting complaintsa) Time
(onset , duration , frequency , course)b) Place (site)c) Quality (character e.g. of pain ,
composition of vomitus)d) Quantity (severity of pain , amount of vomitus)e) Provocative /
alleviative factors / variations (diurnal or seasonal)f) Associated symptomsg) Treatment if
any3) Systemic inquirya) General (weight loss , appetite)b) CVS (shortness of breath on
exertion , shortness of breath and sweaty onfeeding, cyanotic spells, squatting, fainting or
syncope, cyanosis, edema, chestpain/palpitations)
2. 2. c) Respiratory system (sore throat, earache, cough, wheeze, frequent chestinfections,
history of aspiration, hemoptysis)d) Gastrointestinal system (abdominal pain, vomiting,
jaundice,diarrhea/constipation, blood in stools)e) CNS (fits, syncope/dizziness, headache,
visual problems, numbness/unpleasantsensations, weakness/frequent falls, incontinence)f)
Genitourinary system (stream, dysuria, frequency, nocturia/enuresis,incontinence,
hematuria)g) Rheumatological system (limp, joint swelling, hair loss, skin rash,
drymouth/mouth ulcers, dry or sore eyes, cold extremities)IV. BIRTH HISTORY(Important in
neonatal, genetic or developmental case) ANTENATAL HISTORY (H/O PREGNANCY)1) H & N
status (Health and nutritional status of mom duringpregnancy)2) Illness during pregnancy
(HTN, DM, pre-eclampsia, antepartumhaemorrhage)3) Infections during pregnancy (rubella,
UTIs, syphilis, T.B.)4) Drugs (iron, multivitamin, other drugs with dose, duration and atwhich
time of gestation)5) X-ray (h/o irradiation in 1sttrimester)6) TT (maternal vaccination against
tetanus)7) Past obstetric (problems with previous pregnancies, stillbirths,miscarriages, birth
weight of previous children, prematurity, bloodtransfusions) NATAL HISTORY (H/O
DELIVERY)1) Place of delivery (hospital/home)2) Conducted by (dai/trained health
visitor/doctor)3) Sterilization technique for instruments4) Gestation time (length)5) Rupture
time (time of rupture of membranes)6) Labour time (duration)7) Presentation and type of
delivery (SVD, forceps, vacuum extractionor C-section)8) Sedation/analgesics during labour9)
Complications (abnormal bleeding) POSTNATAL HISTORY1) 1STcry
(immediately/cyanosed/apneic)2) Basic problems (need for resuscitation, problem with
respiration,sucking/swallowing)3) Birth weight4) Birth injury5) Convulsions, cyanosis,
jaundice, fever, rash6) Procedures (exchange transfusion, umbilical artery
catheterization,drugs)
3. 3. V. FEEDING HISTORY(Significant in child < 2 years , anemic or malnourished)1) Onset of
feeding (after how many hours)2) Type of feed• Breast-fed (duration)• Bottle-fed (at what
age, composition of formula, amount, frequency, dilution)3) Supplements (vitamin, iron)4)
Weaning (when, what, amount, frequency)5) Current diet/change in diet during illnessVI.
IMMUNIZATION(check vaccination card * )1) Types of Vaccinations given2) Age at which
started and by whom3) Doses & adverse effectsVII. DEVELOPMENTAL HISTORY1) Achieving
age of various milestones• Smiling• Ability to hold neck• Sit• Crawl• Stand• Walk• Talk•
Control of bladder and bowel2) Compared with normal for this ageVIII. PAST HISTORY1)
Significant illness in the past (esp. diarrhea, respiratory infections, fevers, fits, jaundice)2)
History of similar complaints in the pastIX. PERSONAL HISTORY1) Particular habits of child2)
Details of class, school and interest in studies3) Any missed school attendance4) Behavior of
the child at school and relationship with other childrenX. DRUG HISTORY1) Any medications
used (frequency, dose, adverse effects)2) Allergy to any drug3) H/o Mom drug usage ** (in
neonate or breast fed baby)
4. 4. XI. FAMILY HISTORY(Important in chromosomal, hereditary, infectious diseases)1) Age of
mother and father? How long married?2) Consanguinity ***3) Parents’ health (present and
past)4) Siblings• Number• Age and sex• Illness• Any death (cause if known or symptoms of
illness before death)• Stillbirths, miscarriages5) Grand parents’ health (esp. if living with
family)6) Health of uncles, aunts and their children (if inherited disorder suspected)7) DO
MAKE A FAMILY TREE ***XII. SOCIO-ECONOMIC HISTORY1) Parents’ education and
occupation2) Family income3) House (made of, persons living, size)4) Cleanliness and general
hygienic conditions5) Source of drinking water6) Any pets at home