HISTORY TAKING - dizziness

- Easy fatigability
Demographics - Palpitations
- Name: - Syncope
- Sex:
- Age: b) RS;
- Date of birth: - breathlesness
- Place of birth: - Cough
- Tribe:  Productive/non
- Religion: productive
- Residence: - Sputum
- Informants: ?pt/parent  Color
- Language of interview:  Consistence
- Is it clinic referral/not  amount
- Date of hx taking: - Wheeze
- Chest pain
Presenting complaint: - Haemoptysis
- Headache 2/7 - Sore throat
- Body hotness 1/7

Development of Symptoms: c) GIT;

- Detailed info about child’s illness - Abdominal pain
- It should be recorded - Appetite
systematically to give separate - nausea
paragraphs and headings to each - Vomiting
new dateline, rather than giving - Haematemesis
the whole hx in essay form - Heart burn
- Duration - Diarrhoea
- Onset - Constipation
- Progress - Steatorrhoea
- Episodes - Malaena
- Seasonal diurnal variation
- Aggravating factors d) GUT;
- Relieving factors - Pain
- Complete the whole system - Haematuria
affected - Oliguria
- Anuria
- Polyuria
Review of Systems: - Frequency
a) CVS; - Nocturia
- Chest pain - Dysuria
- Dyspnoea - Urgency
- Exertion dyspnoea - Incontinence
- Orthopnoea - Enuresis
- Paroxysmal nocturnal - Slow stream
dyspnoea - Hesitancy

1|Page
 - Terminal dribbling  Breast feed
- Urethral discharge  Passed meconium and
urine

e) CNS; - Neonatal
- Headache  Convulsions
- fainting  Jaundice
- Weakness/paralysis  Fever and vomiting
- convulsions  Grunting, tachypnoea
- Abnormal movements  Pregnancy, labour, birth
- Double vision wt.
 Perinatal problems and
method of feeding
f) MSS;
- Skin rash
- Joint/bone pains
- Joint swellings Immunisation Hx:
- Yellowing of eyes/palms - BCG-look for scar
- Pentavalent
Past Medical Hx: - measles
- Hospital admissions - Under 5 card
- Hx of similar illness - Immunisations given
- Operations
- Accidents, injuries
- Hx of chronic disease Nutrition Hx:
- Breast feeding
Drug Hx: - Weaning feeds?
- Past and present medications - ?Type of feeds and how much
- Herbal medication daily
- Allergies  Morning
 Afternoon
BIND  night

Birth Hx: Developmental Hx:

- Birth weight Movement and posture
- Antenatal - Head control
 Regular ANC - Sitting
 Any hx of fever - Crawling
 Drug hx - Standing with support
 Irradiation - Standing without support
 TT, Fe2++, FA - Walking

- Natal Vision and manupilation

 Term/preterm - Follows a moving person
 Type of delivery - Looks at a toy held in midline
 Did baby cry at birth - Watches his hands

2|Page
 - Pulls at his clothes, tries to grasp
objects Socio-economic Hx:
- Transfers objects from one hand - Housing
to another - Occupants
- Develops finger-thumb grasp - Ventilation
- Toilets
Hearing and speech - Water
- Vocalizes with gurgle - Income
- Turns head to sound - Smoking
- Laughs - Water source
- Says da ba ka - Toilet
- Says one word with meaning Personal history
- Says three words with meaning - Ability to mix with friends
- Begins to join words together - Bowel and bladder habits
Summary of Hx:
Social behavior
- Smiles Differentials/Impression:
- Recognizes mother
- Tries to feed himself
- Waves bye bye PHYSICAL EXAMINATION
- Understands simple questions
- Asks for things by pointing at General Examination:
them - Pt was conscious/not conscious
- Febrile
- Nourishment
- Pallor
Family Hx: - jaundice
- ?Parents alive - cyanosis
 Age - oedema
 occupation - lymphadenopathy
- Siblings - dehydration
 Number - If child appears very ill, first
 Healthy sick assess: Airway, Breathimg,
 Draw pedigree chart Circulation, Disability, Exposure
 Contact hx (ABCDE)
 Any inherited hx - JCCOP
 Asthma - Oral cavity – ?membrane lesions
 T.B - Teeth - ?carries
 Epilepsy
 Diabetes Vitals:
 Sickle cell disease - Temp
 Deaths incl miscarriages, - Respiratory rate
stillbirths, terminations - Pulse: ?regular, full volume, RR
- Family illness and allergies and RF delay
- Family tree (asthma, TB, HTN, - BP
DM, epilepsy)

3|Page
Anthropometric Measurements: - Inspection; ?skin, inverted
a) Weight; umbilicus, scars, dilated vessels
- Initially 12% loss - ?moving with respiration
- Regains birth wt by 10th - Liver/spleen
day - Abd masses
- Then gains 30g/day - Ballotable kidneys
- Wt doubles by 5 mo - Renal angle tenderness
- Wt trebbles by 1 yr - Shifting dullness
- Bowel sounds
b) Height; GUS:
- 50cm at birth Skin(Scratch marks, purpura)
- 75cm at 1 yr
- 100cm at 4 yr MMS:
- Then gains 5cm/yr Deformity, fractures, mobility
tenderness pain, muscle wasting.
c) Occipito-frontal circumference;
- 35cm at birth CNS:
- 40cm at 3 mo - Mental state
- 47cm at 1 yr  OTPP
- 0.5cm/yr btn 2-7 yr - Gait
- 0.3cm/yr btn 8-12 yr - Cranial nerves
- Motor
d) mid-arm circumference;  Weakness in out stretched
hand
 Distal or proximal wasting
RS:  Muscle tone
- chest; ?symmetrical, deformities  Reflexes
- scars; ?tatooes, surgical - Sensory
- tenderness - general
- trachea; ?central
- chest mvts Urinalysis:
- percussion - SG: 1.020
- breath sounds; ?bronchial, - Leukocytes: 500/Ul
vesicular - Nitrites: -ve
- added sounds - Bilirubin: -ve
- vocal resonance - Glucose: normal
- pH: 5
CVS: - blood: -ve
- Distended neck veins - ketones: -ve
- Precordium - proteins: 15mg/dl
- Apex beat
- S1, S2 Summary of Examination:
- Added sounds
Differentials/Impressions:

Per Abdomen:

4|Page