Pediatric History Writing o Good cry?

- Date and time gathered - Birth weight

- Informant (usually mother or father) - Perinatal complications
- % reliability – Determines how accurate the o Sick at birth or during in the nursery
information from the individual you interviewed o Jaundice, meconium staining?
so consultants will be aware. o If preterm, the baby may stay for a
while in the hospital
General Data - Duration of stay in the hospital or lying in clinic
- Name (initials) o Lying clinic – d/c within 24 hrs
- Age o Hospital – d/c within 2-3 days
- Sex
- Nationality Post Natal History
- Religion - Feeding History
- Address - Growth and Development
- Date of Birth - Immunization History
- Place of Birth - Past Medical History
- Date of Admission
- No. of admissions Feeding History
- Place of admission - Type of feeding
o Purely breastfed or bottle fed with milk
Chief Complaint o Mixed feeding
- Reason for admission o Duration
- Age when semi-solids were introduced
HPI o Usually at 6 months
- Onset of illness and duration
- Nature and character Growth and development
- Severity - Approximate age when major development
- Aggravating Conditions milestones were acquired
- Relieving Conditions - Gross motor, fine motor, social, language
- Associated signs and symptoms - The chart is in BATES
o Ex. Fever – may have cough, coryza
o Abdominal pain – vomiting or diarrhea Immunization History
- Problems in feeding and sleep - Enumerate the immunizations received
- Medications – Generic name, brand name, dose - No. of doses received
(very important because it is based on weight to - Where the immunization was done: local health
avoid under or overdosing) and response center or with a private physician

Pre-natal History Past Medical History

- Mothers age (at the time of pregnancy) and OB - Past illnesses
score at the time of pregnancy o Chicken pox
- Pre-natal care visits o Measles
- Laboratories taken (include results and findings) - Previous hospitalizations and surgery
(CBC, UA, Hep B, HIV, Group B Strep testing) - Food and drug allergies
- Illnesses during pregnancy (UTI, Measles @ 1st
trimester) Family medical history
- Drugs taken during pregnancy - Present state of health of parents and siblings
- Smoking - Presence of chronic diseases
- Alcohol intake - Presence of heredofamilial disease

Natal History Social History

- Age of gestation (preterm, term or full term, - Ages of their parents and their work
post term) - Brief description of their dwelling place
- Birth rank - Water source – especially for drinking
- Mode of delivery (normal vaginal, caesarian - Garbage disposal
forceps)
- Where delivered (hosp, home, lying in clinic)
- Who attended the delivery (resident, physician,
midwife)
- Condition upon delivery (APGAR score)