PEDIATRICS HISTORY TAKING

HISTORY TAKING
1. PATIENT PARTICULARS
a) Name: Important for identity, knowledge of sex, caste, religion, community,
psychological benefit
b) Age: Certain diseases are prevalent in certain age groups like in less than 1 there
is increased prevalence of pneumonia, diarrhea.
c) Sex: Certain diseases are prevalent in certain sex groups like X linked diseases
like color blindness, hemophilia, in males. SLE more common in female.
d) Address: Identity, certain diseases are endemic in certain geographical location
like malaria in terai, thyroid related diseases in Himalayan region, also gived idea
about community description.
e) Religion: Certain diseases are prevalent in certain religious group. Cultural
practice differ from religion to religion e.g. throwing away colostrums, giving pre-
lacteal feeds.
f) Informant: Child himself, father, mother, grandmother.
g) Reliability: If mother then reliability is good. As may be other may know about
what the child is having now but may not know about birth, developmental hx.
h) Date of admission:
i) Date of examination: As we can know the progress.

2. CHIEF COMPLAINTS/ PRESENTING COMPLAINTS

Those complaints with which the child was brought to the hospital. Features:
a) Chronological( arranged in terms of their appearance)
b) Duration of each complaint
c) In patients own language
d) Status of complaints till date should be given e.g child develops abnormal body
movement on 5th day of hospitalization then also we mention it as
abnormal body movements X 5 days.

Example: A child was well 10 days back. To start with he had fever which lasted
for 5days. The child developed a rash over the body on 3rd day of fever which
lasted for 4 days. As soon as fever subsided, parents noticed that the child is in
altered sensorium which gradually increased and now the child is unconscious and
does not responds to verbal commands. The child had 2 episodes of left sided
convulsions 3dys prior to admission and since then he is not moving left side of the
body.

Chief complaints
a) Fever X 5days which was 10 days back
b) Rash over the body X 4days 7days back
c) Altered sensorium X 5 days
d) Two episodes of left sided convulsions X 3days
e) Unable to move left side of the body X 3days
EXAMPLES
Fever – Onset – acute or insidious
Duration -
Character-
Continuous – with in 24 hrs if the temp does not touch the basal temp &
does not fluctuate more than 1° C
Remittent – daily fluctuations of temp exceeds 2° & does not touch the
basal temp (remains throughout the day)
Intermittent – temp touches basal temp & exceeds 1° C & present only
several hrs during the day
Quotidian – a paroxysm of intermittent fever occurring daily
Tertian – when on alternate days
Quartan – 2 days intervene btw consecutive attacks.
Severity – high grade / moderate / low grade

Associated symptoms – chills/rigors

D/D: Intermittent Malaria
Pel ebstein type regular bouts of fever & afebrile periods
Kalazar touches baseline twice in 24 hours
RemittentAbscess, TB, CA
Continuous Fever  Typhoid, UTI, Lobar Pneumonia
Rigors bacterial\ infections
Joint & muscle painArthritis (rheumatoid), SLE
 Fever
Onset, Duration, Temperature, Pattern, Progression, Associated symptoms

Cough – Duration
Frequency
Character
Productive/ Non productive
Diurnal Variations
Aggravating factors, Reliving factors
Postural relationship

Sputum- Color – Yellow - purulent

Green pseudomonas pneumonia
Colorless allergic, viral
Rusty brown streptococcal pneumonia
Consistency – Jelly - asthma
Quantity – copious – COPD
Haemoptysis - Present/absent
- Nose bleeds

Vomiting - regurgitations of feeds

Duration
Frequency
Severity
Content: Food materials
Bile or fecal matter – intestinal obstruction
Blood – hematemesis – ulcers (gastric/duodenal)
- Gastro esophageal varices
- CA stomach
Associated with: anorexia, nausea
Aggravating factors
Postural relationship
 Pain – S. T. A. R
Site
Duration
Time
Severity- low
Moderate
Severe

Character - Burning
Piercing
Boring
Colicy

Radiating or referred

Headache
Severity
Area

3. HISTORY OF PRESENT ILLNESS

Parts
a) Elaboration of chief complaints
b) Negative history
c) Treatment history/ course of disease in hospital stay
Elaboration of chief complaints: In General in onset- time and nature, duration,
frequency and consistency, evolution and severity, aggravating features & reliving
factors and associated features.
Negative history: In general it is done to rule of involvement of a system, identity
the nature and etiology of the disease progress, access the severity and
complications, and differentiate between likely diagnosis and probabilities.
Treatment history: The course of illness after admission, t/t history and now the
condition of the illness.
4. PAST HISTORY

 History of similar illness in the past. Details about the onset of illness( k k
bhayo), symptoms, treatment hx, number of episodes & frequency of
relapses.
 History about any communicable diseases
 Any major illness in the past
 Any surgeries, injuries or any hospitalization

Important past history

IN Respi Recurrent pneumonia, Rheumatic fever

CNS Epilepsy, Convulsions, Cyanotic spells
GIT Jaundice, transfusion/ injection, recurrent abdominal colic,
diarrhoea

5. BIRTH HISTORY
a) Antenatal history

 Age of the mother when she conceived the child: extreme age i.e teen or
advanced pregnancy affects growth of fetus and also is associated with
certain genetic diseases eg downs syndrome
 No of visits the mother took( ANC)
 Supplementations like Fe, Ca, Folic acid taken or not:
 Tetanus vaccination taken or not
 Any acute illnesss present: Fever with rash( susceptibility for TORCH
infection)
 Any chronic illness: Pre-eclampsia, Eclampsia, Diabetes mellitus,
Polyhydramnios, Polypregnancy, Placenta previa, Abruptio placenta
 Smoking
 Alcohol
 Radiation exposure
 Any drug intake( Terratogenicity)
  Weight gain during pregnancy: according to BMI, related to fetus weight;
IUGR, excessive during PIH
 Diet in pregnancy
 Rubella as most effect during 1st trimester – 6-8 weeks up to 11 weeks and it
causes congenital rubella syndrome – cardinal symptoms - C –cataract D-
deafness C-cardiac defects
 Age of mother during pregnancy - >35 female more chance of downs
syndrome
 Minimum of 3 visits it is ka Booked case
 Mother is immunized for tetanus or not

b) Natal History

 Mode of delivery (if c/s indication)

 Place of delivery
 If delivery at home- who was the attendant
 Cutting of umbilical cord
 What was applied at umbilical stump
 Labour period
 Rupture of membrane
 Colour of liquor- indicated conditions like meconium aspiration, Rh
incompatibility
 Period of Gestation
 Crossing of EDD

Condition of the baby

 Weight of the baby/ if delivered at home then size of the baby:

 Condition of the baby:
 APGAR score

A: Appearance
P: Pulse
G: Grimase
 A: Activity
R: Respiration

 For birth asphyxia

a) cried immediately after birth
b) movement after birth
c) any bluish discoloration
d) suckling of breast:

c) Post natal

 Any complications?
 Neonatal jaundice; kaile harayo?
 Passing of meconium and urine
 Initiation of breast feeding
 Prelacteal feeds
 Jaundice –
 Physiological – occurs after 3 days up to 7 week
 Pathological – occurs with the 1st 48 hrs.

 Jaundice is not seen in fetus because the bilirubin which is released will be
conjugated by the mother ….but when the fetus is born which process ceases

 If very high level of bilirubin it can cause kerniterus.

6. Nutritional history( feeding history)

 Prelacteal feeds?
 Colostrums
 Duration of breast feeding
 Duration of exclusive breast feeding
 Any other feed given
  If not breast fed
Starting age of formula feeding
Dilution
Amount
Frequency
Nature of formula – dried or fresh milk
Mode of feeding – bottle or spoon

 Complementary feed
a) Time
b) Type of weaning
c) Amount
d) Frequency
e) Other supplementary feeds given like vitamins
f) When was solid food given
 Present dietary history
a) Ask about the food 24hrs prior to the present illness period
b) Calculation of approx. calorie & protein taken by the child
c) Calculation of approx. calorie & protein to be taken by the child
 Recommended calorie:
1st 10kg= 10 X 100 Kcal
2nd 10kg= 10 X 50 Kcal
Next kg = Kg X 25 Kcal

Hints:
 Teaspoon: 5 ml
 Tablespoon: 15 ml
 Cup/ katori: 150ml
 Glass: 250 ml
RDA of a child:

Calories Protein

x<6 months: 110 Cal/kg/day 2.0g/kg/day

6 m – 1 year: 101-104 Cal/kg/day 1.5g/kg/day

 1-3 years: 1240 Cal/day 22g/day

4-7 years: 1690 Cal/day 30g/day

7-9 years: 1950 Cal/day 40g/day

7) DEVELOPMENTAL HISTORY
Developmental milestones:
We ask for achievement of developmental milestones. We first ask about the
developmental milestones
a) Gross Motor

3 mo Neck Holding
5 mo Roll over
6 mo Sit with support
7 mo Sit without support
9 mo Stand with support
10 mo Crawls on ground( bame sarne)
11 mo Stand without support
12 mo Walks with one hand held
18 mo Runs & crawls up and down stairs
2 yrs Climbs upstairs with both feet on the step
3 yrs Climbs upstairs with one foot per step, rides tricycle
5 yrs Rides bicycle

b) Fine motor

4 mo Bidextrous reach
6 mo Unidextrous reach
9 mo Immature pincer grasp
12 mo Mature pincer grasp
18 mo Towers of 3 blocks

c) Personal and social smile

2 mo Social smile
3 mo Recognizes mother
6 mo Recognizes stranger/ stranger anxiety
9 mo Waves bye bye
12 mo Comes when called
18 mo Copies parents in task
2 yr Asks for food, toilet
3yr Shares toys, knows full name and toys
5 yr Can dress and undress

d) Language- hearing and speech

1 mo Alerts to sound
3 mo Coos
4 mo Laughs loud
6 mo Monosyllables
9 mo Bisyllables
12 mo 1-2 words with meaning
18 mo 8- 10 words with vocabulary
2 years 2-3 word sentences
3 years Asks questions; knows full names and gender
Developmental delay: Its is used to describe a baby or young child who is slower
than expected in achieving the normal developmental milestones.
Dev. Quotient= Dev. Age X 100
Chronological age
100- Ideal
85-99- Delay
71-84- Mild to moderate delay
<70- Secret delay
Global delay: If two or more domain of developmental delay
Dissociative delay: If there is one particular delay

What class he / she studying in and performance in school

8) IMMUNIZATION HISTORY

a) BCG 0.05 ml At birth Intradermal

b) DPT- Hep B- 3( 0.5) ml 6, 10, 14 wks Intramuscular
HiB
c) OPV 3 ( 0.5) 6, 10, 14 wks Oral
ml
d) PCV 3( 0.5) ml 6, 10 wks 9 mo Intamuscular
e) IPV 1 (0.5) ml 14 wks Intramuscular
f) MR 2 (0.5)ml 9, 15 mo Subcutaneous
g) JE 1( 0.5) ml 12 mo Subcutaneous

0 month BCG 1 pricks

6 wks DPT, Hep B, HiB, OPV, PCV 2 pricks
10 wks DPT, Hep B, HiB, OPV, PCV 2 pricks
14 wks DPT, Hep B, HiB, OPV, IPV 2 pricks
9 mo MR, PCV 2 pricks
12 mo JE 1 pricks
15 mo MR 1 pricks

 Vaccine taken as per National Immunization Program

 Any adverse reaction following immunization

FAMILY HISTORY

 Pedigree chart
 Type of marriage: Consanguineous/ non- consanguineous
 Number of children, their age and gender, death, abortion or still

SOCIO- ECONOMIC HISTORY

 Education: Of patient, father, mother

 Occupation: Of father and mother
 Family income: Total income of family
 Other:
: Housing
: Cross ventilation
: Mode of cooking
: Sanitation
: Water supply

Kuppuswamy’s socio economic status scale

 ANTROMETRIC MEASUREMENTS

1. WEIGHT

 Sensitive index
 Best measurement of nutrition and growth
 Measurement: Electronic baby scale( basket/ pan baby scale)- measures upto
10 gm increment
: Bathroom scale- max upto 100kgs for > 6yrs - measures upto 100 gm
increment
: Salter spring balance- max upto 25 kg for < 6yrs of age

METHOD
 1) Child should be in bare minimum cloths and without shoes. Infants
should be weighed naked and older children in brief and vest.
2) Scale should rest in a firm, stable and even surface( uncarpeted) surface
3) Before starting 0 should be fixed
4) IN case of INFANTS: Baby is placed in such a manner that the weight
evenly distributes. If a diaper is worn, the weight of which should be
substracted.
5) IN case of CHILDREN: They are asked to stand in the center of the pan,
weight distributed evenly in both feet and child is not holding onto anything.
6) Weight is read from front and not from slide.

NORMAL WEIGTH GAIN

Normal weight at birth 2500-3999 gms

Doubles 5 mo
Triples 1 yr
Quadruples 2 yr
Gains 2Kg/ yr 6 yrs
Gains 3Kg/ yr 7 yrs
For 7-12 yrs-( Age(yrs) X 7 -5) / 2

2. STATURE

A) LENGTH FOR < 2YRS ( INFANTOMETER)

Method: It measures the supine length of infants and children using a horizontal
wooden board limited by two perpendicular vertical wooden plank: one of which is
headpiece which is fixed and the other is foot piece which is mobile.

Birth 50 cm
1st year 25 cm+ ie 75 cm
2nd year 12.5 cm+
3rd year 7.5 cm+
Expected Age in yrs x 6 + 77 cm
3. BODY CIRCUMFERENCE
