La Consolacion University Philippines

College of Medicine
Internal Medicine Preceptorial
Pedia History

Date: __________________
Time: __________________
I. General Data
● Informant’s name:
● Patient’s name:
● Age:
● Sex:
● Date of birth:
● Place of birth:
● Race:
● Religion:
● Present address:
● Number of hospital admission:
○ When
○ Where
○ Cause(?)
● Date of hospital admission:
A. Reliability factors:
● Relationship to the patient:
● Amount of time spent with the patient:
● Degree of involvement in the care of the patient:
● Educational Attainment:
II. Chief Complaint
● Gaano na katagal

III. History of Present Illness

● (Signs and symptoms described in chronological order from the start of the illness)
● (If the patient is a newborn and the present problem are related to the prenatal and
perinatal period, the maternal and birth history should be incorporated in the HPI)
 ● Onset (Sudden/rapid, gradual)- when did the lesion start, same symptoms with the family,
allergy to medications.
● Associated signs and symptoms: fever, cough? Rashes pattern of vesicles
● Intake of medications,
● History of immunizations
● Similar lesions in the past
● Childhood diseases
● Skin injuries past?

● Duration
● Characteristic
● Location
● Intensity
● Timing
● Precipitating
● Aggravating
● Alleviating
○ Medication/treatment given

IV. ROS
General:
Good morning, my name is ________, also a medical student of LCUP, and I’m here to ask
about what we call

REVIEW OF SYSTEMS, in this part of the interview I ask a series of short questions regarding
several aspects of the patient's body systems to make sure that we didn’t miss anything. Is that
okay?

● General Survey: weight loss?, chills?, sweats?, lethargy? activity level?

● Skin: excessive dryness or sweating, cyanosis, pallor, jaundice, rash, skin lesions
● Head and Neck: lesions, mass, trauma, swelling, headache, pain, stiffness
● Eyes: tearing, Itching, redness, discharges, pain, dryness, infection
● Ears: discharges, pain, tinnitus, vertigo, hearing loss
 ● Nose and Sinuses: congestion, colds, sneezing, pain,
● Mouth and Throat: soreness, pain, infection, ulcers, hoarseness, dryness, gum
bleeding, dental caries, tongue lesions, swallowing problems,
● Neck: limitation of movement, mass
● Breast: pain, lumps, nipple discharge
● Respiratory: hemoptysis, pain, dyspnea, cyanosis, chest pain
● Cardiac: edema, cyanosis, palpitations, murmur, known CHD
● Gastrointestinal: Vomiting, bowel movements, constipation, diarrhea, jaundice, food
intolerance
● Genitourinary: urethral discharge, hematuria, dysuria oliguria
● Extremities: edema, swelling of joints, stiffness, numbness, intermittent claudication,
limitation of movement
● CNS: seizures, headaches, tremors, difficulty in balance or gait
● Musculoskeletal: deformities, pain, swelling, tenderness, cramps, weakness, trauma,
sprains, fractures, stiffness, backache,
● Hematologic: anemia, bleeding, bruising, transfusions, malignancy
● Endocrine: excessive thirst polyuria

V. Past Personal History

A. Gestational History
a. Mothers age during pregnancy:
b. Parity:
c.

d. Health:
e. Nutrition:
f. Infections:
g. Intake of drugs:
h. Roentgen exposure:
i. Duration of gestation:
B. Birth History:
● Term:37 wks
● Premature/Postmature: <37wks
● Manner of delivery:natural,CS,water birth,or unassisted birth
● Persons who attended the delivery:ob,nurse, or midwife
 ● Birth weight:
● Newborn care: drying, cord cut, mother child skin-to-skin contact, breastfeeding
C. Neonatal History:
● Apgar score:
○ Activity (muscle tone; active, flexed arms and legs)
○ Pulse (over 100 bpm)
○ Grimace (reflex irritability; prompt response to stimulation)
○ Appearance (skin color; pink, pale, blue mucous membranes)
■ Cyanosis: bluish skin, lips, fingers and toes
■ Pallor: paleness of skin; anemia
○ Spontaneous respiration or required resuscitation:
■ Cry: irritability on mood, lack of O2 then need for oxygenation
● Jaundice (age of onset): Physiologic(neonatal) or pathologic(inc. bilirubin)
● Convulsions: muscle jerking, repetitive facial movements
● Hemorrhage: bleeding disorder or insufficient vit. K(clotting factor)
● Respiratory or feeding difficulties: Respi. Distress syndrome(RDS)
● Congenital abnormalities: Birth defects
● Birth Injury: Breech, fracture, bruising

D. Feeding History:

● Type of feeding:
○ Exclusive breastfeeding or mixed with formula feeding:
○ Frequency per day:
○ Duration of feeding at each breast:

● If not breastfed: reason for not breastfeeding:

 ○ Formula used, dilution and amount given per day:
○ Bottle feed or cup-fed:
● Complementary foods:
○ Age introduced:
○ Frequency of feeding per day:
● Usual food intake:
● Actual Caloric Intake:
ASSESS:
● Appetite:
● Computation for the ACI compared to RENI
E. Immunization History
● Type of Vaccine
● Date and place of administration
● Any untoward reactions
● PPD skin test
○ Result?

VI. Developmental History

A. Young children (Ages 1-5 years old)
● Urinary incontinence: during day and night ( hirap sa pagwiwi o pagbawas ng
ilang beses ng pagwiwi)
● When did the baby had his first teething and loss pattern ( nagngipin ng bata)
● Toilet training and when did it start? [Nakapagstart na ba magtoilet training?
Kelan? Kamusta ang pagtrain sa kanya?]
 ● Developmental milestones ilang buwan noong napansin na makita ang mga ito
○ Pagsasalita ng maiikli na salita
○ social smile
○ rolling over
○ walking
○ response to environment

● observed: ask about frequency , onset , what do you do when they are showing
this kinds of behaviour (gaano kadalas, kelan na obserbahan, ano po ang
ginagawa niyo sa ganitong situation)
○ temper tantrums lately
○ head banging (pagpukpok ng kanyang ulo sa pader)
○ phobias PICA
i. takot na nagduduot ng sobrang pagiyak sa isang bagay
ii. (eating unnecessary things like paper, wood etc)
○ night terrors
i. (crying in the middle of sleep) (pagiyak pagkanatutulog)
○ waking up in the middle of sleep
i. (pagkaistorbo ng pagtulog)
Denver Developmental delay when there is developmental delay:
https://doctorguidelines.com/2016/08/03/child-development-assessment-developmental-
milestones-and-denver-developmental-screening-test/

B. Middle Childhood
School:
● Specific problems
○ problema sa eskwelahan, sa grade
○ may subject ba nahihirapan . kamusta ang kanyang grades , pano siya
nagcocope up
● Present Grade
● Interaction with peers
○ mabuti ba ang pakikisama sa kaklase at kaibgan
○ madalas ba makipagaway
● Extra curricular activities at school and outside of the school
○ may iba bang ginagawa bukod sa pagaaral sa klase
■ kasali ba sa mga club sa skwela o kaya sa organization

● Sexual Maturity Testing (Using Tanner’s Maturity Rating)

○ for girl:
■ is breast ( napapansin na paglaki ng dibdib , gaano kalakiang
pinagbago)
 ■ sa ari : may napansin ba na oagbabago? pagkakaroon ng buhok
( quality, gaano kadami hanggang saan)

● for boys:
○ sa pubic hair
i. napapansin na pagkakaroon ng buhok sa paligid ng ari
ii. gaano kadami,
iii. itsura ? mahaba ang buhok? may pagkakulot ba? hanggang saan
○ Penis
i. may napansin ba na pagbabago
1. yung laki
○ Testes
i. laki, kulay
C. Adolescent
● Are you involved in a relationship?
● Have you ever been involved in a relationship?
 ● How was the experience for you?
● How would you describe your feelings toward guys/girls?
● How do you see yourself in terms of sexual preference?
● sexual activity
● contraceptive use if applicable
● pregnancy if applicable
For females;
● Menarche
● Last Menstrual Period
○ Problems with menses

Suicidality:
● depression, suicidal ideation, attempts to hurt self
● how is the relationship with family
● how much sleep do you get daily
● how are your grades in schools
● did you went on a diet
● how are your friends? how is your relationship with them
Safety:
● Do they feel safe at your home or your neighborhood
○ have told this to anybody or your parents
● presence of guns
● previous or current kind of abuse
● seatbelt, helmet,
● sports that they are in to
○ sports safety measure
○ hazardous activities

Family :
● Family genogram if present
● What type of family are they?
○ single, married, separated , blended
○ family occupations
○ history of addiction in family
○ parent reaction about alcohol, drugs
○ parenteral rules
○ are they ill? physically or mentally challenged?
Friends:
● common interests of you and your friends
● are they in a gang or cult
 Image
● Height and weight perceptions
● Body maculature and physique
○ how they dress
○ jewelry
○ tattoos
○ body piercing as fashion trends/ other statement

Spirituality & connections

● are they in a certain organization in their religion
● personal spirituality and and practices and beliefs
Threat and Violence
● did they though of self harm or harm to others
● cruelty to animals
● running away from home
● guns
● fight involvement
○ Why
○ what happened
○ when
○ where
● stealing
● fire setting

VII. Past Health History

A. Past Illnesses (Age, when contracted, severity, complications)
● Nadala na ba si baby sa hospital dati?
○ Hospitalization
■ Why?
■ Age
■ Place
○ Operation
■ Why?
■ Type
■ Age
■ Place
● Allergies?
● Contagious Illness (nakakahawang sakit)
○ Measles (Tigdas)
○ Varicella (Chickenpox/Bulutong)
○ Mumps (beke)
B. Family History
● Ask for parents age:
○ Mother
○ Father
● Ilan po silang magkakapatid and pang-ilan po si baby?

●
● Matanong ko na din may history po ba kayo o sa pamilya niyo ng mga sakit?
Tulad po ng hypertension? DM? Tuberculosis? Asthma? Sakit po sa puso?
Cancer?
● Paternal Side
○ Father
○ Grandfather
○ Grandmother
● Maternal Side
○ Mother
○ Grandfather
○ Grandmother
● Siblings
C. Socioeconomic History
● Parents – age, occupation, state of physical and mental health
● If not living – ask the age of death, cause and nature of symptoms, history of
consanguinity
● Matanong ko lang po ilang taon na po kayo?
○ e ang asawa/hubby niyo po?
● Matanong ko din po ano po pinagkukunan niyo sa araw araw na gastusin?
○ Kayo po bang dalawang mag-asawa ang nagttrabaho?
● Siblings – number, ages, state of health
● If not living – ask for age of death and cause
● Aside po kay baby may mga anak pa po ba kayo?
 o Ilan po?
o Edad
o Sakit?
● Living circumstances – place and nature of dwelling, number of persons
living in the house.
○ Saan po nakatira? Ano ang tinitirahan?
○ Ilan at sino sino ang kasama o nakatira sa bahay ninyo?
● Economic circumstances – members of family who work, sources of funds
● Sapat po ba ang kinikita para sa pang araw araw?
D. Environmental History
● Exposure to cigarette smoke and other environmental pollutants (*include
what type of pollutant and duration of exposure)
○ Meron po bang naninigarilyo sa pamilya?
○ Gaano katagal na po?
● Meron po bang malapit na piggery sa inyo?
● Ano po ang trabaho nyo? *factory worker
○ Sa trabaho nyo po ba ay gumagamit kayo ng mga mask o proteksyon sa
usok?
● Malapit po ba sa factory ang bahay nyo?

● Garbage disposal (segregation, recycling)

○ Tuwing kelan dumadating ang kumukuha ng basura
○ Hinihiwalay nyo ba ang ayon sa uri nito ang mga basura

● Sewage disposal

● Water source, drinking, washing

○ Saan nyo po kinukuha pinang iinom nyong tubig sa bahay?
○ Pinakukuluan nyo po ba ito? *if tap water