History *pedia edition* @RAYYAN.

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Personal data :
1-name 2-age/DOB 3-sex 4- nationality

5-residence 6- date of admission 7-mood of admission 8-mood of transfere

9-source of hx ? And is he reliable ?

c/c with duration

HPI 1-analysis with SOCRATES or OD PARA CARRE

Onset :

Duration

Progression

Aggravating

Reliving factors

Associated symptoms

Course : timing (all day , night , morning ) , severity : affecting(sleep , eating ,

activity) - related to specific food or activity.

Another : if its symptoms that contain fluid (COPA PC)

Color , odour , presence of blood or pus, amount , related to position , character

Related to specific food or activity

Risk factors:

Else :

2-constitutional symtoms : weight loss, fevers, , anorexia , sweating

4-possible causes

5- symptoms of the system involved

ROS CNS 1- headache

2-weakness
3-blurry vision
4-dizziness
5-abnormal movement
6-loss of consciousness
7-👂
 History *pedia edition* @RAYYAN.T
CVS LEFT SIDE HF :1- orthopnea 2-PND 3-DYSPNEA
RT SIDE HF : 1-LL swelling 2-early statiy
Central : chest pain -> yes —> socrates
Peripheral : claudication -> yes —>when does it
start , how km , with rest ,
Electrical : palpitation
HF OF neonates :Interptud feeding - Sweating of
forhead

RES 1-Cough 2-sputum ->yes how much, color , smell

3- hemoptysis ?

GI 1-Abdominal pain
2-dysphagia
3-vomting and nausea and hematemesis
4-dysphagia
5-constipation , diarrhea
6-melena
7-jaundice
8-heartburn

Renal 1-loin pain 2-oligo-poly-uria 3- dysuria 4-hematuria

5-FUN

Masco 1-Joint pain 2-rash 3- pigmentation 4-muscle

pain

Neonatal hx * important a-Prenatal hx : b-natal hx : C-post natal :

in first 2 y or when child 1-mother follows during 1-Cry immediately or
have developmental or pregnancy ? 1- GA ?(term - preterm - Admitted to NICU ?WHY
Neuro impairment 2-age of mother when full term) AND HOW LONG
conceived ? 2-early rupture of m 2-intubated why and for
3- H/N: 3- place/mode of how long
4-ilness during preg ? dileverey (cs -svd)? 3-birth wt/ injures
HTN - DM - bleeding 4-presentation 4-j/cyanosis/pallor/rash
5-teratogenic 5-problem ? 5- seziure
exposure(drugs-infection
radiation )
6-poly-oligohydraminous
7-fetal movements :
8-problem with previous
pregnancy:(still birth -
miscreage)

Nutritional hx in infants : a-bottle feeding(indication ? at which age , preparation : (formula /

amount / composition / dilution / frequency / sanitation ?
-supplement ?
b-Breast F :
1-Duration and frequency and ist enough ? 2-Technique ? 3-weaning time?
in child ? Quantity / quality ? Dislikes ? Appetite ?

Developmental 1-groos motor

2-fine motor
3-social
4-languge
5-performance at school ?
 History *pedia edition* @RAYYAN.T
PH Surgical : MEDICAL :
1-previous surgery ? 1-simillar conditions (when , how many)
(when where why ) 2-chronic illnesses : when where how he dx?
2-trauma DM - ASTHMA
3-blood transfusion 3- hospital admission : Number? Duration ?

immunisation Check card -> no card ? last vaccine —? Not updated ? Ask why ?—> ask
about adv —-> extra vaccine if indicated.

Hx of contact with 1-infected individual either at home or at school ?

SH 1-SMOKING
2-parents education and income
3-travel
4-pets
5- house conditions

FH 1-similar condition
2-chronic illness
3-inhertied disease
4- consanguinity ?
5-neonatal death or abortion
6-allergy ?
7-pedigree

DH 1-current TTT
2-Past
3-over the counter
4-herbs and vitmans

name - Route - dose Indication - frequency Side effects - change in

dose

Allergy food or drug

ICE i:Thoughts regarding C: E

symptoms

ANYTHING YOU WANT TO ADD

Summary …year old …… known case of/medically free ………… present to the
……….and complain …….c/c……….
+ve findings :
-ve findings : only if its important.

examination
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Growth chart : ht wt and HC

lab:
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Assessment and plan :

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