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Pediatrics history taking

Apr 20, 2013 • 719 likes • 410,444 views

Ramzan Ali

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Pediatrics history taking

1. PEDIATRICS HISTORY TAKING (MY PROTOCOL) I.
PATIENT’S PROFILE II. PRESENTING COMPLAINTS III.
HISTORY OF PRESENT ILLNESS IV. BIRTH HISTORY V.
FEEDING HISTORY VI. IMMUNIZATION VII. DEVELOPMENTAL
HISTORY VIII. PAST HISTORY IX. PERSONAL HISTORY X.
DRUG HISTORY XI. FAMILY HISTORY XII. SOCIO-ECONOMIC
HISTORY I. PATIENT’S PROFILE 1) Name 2) Age (Date of
Birth) 3) Sex 4) Address of parents 5) Date of admission II.
PRESENTING COMPLAINTS (Use parents’ own words +
chronological order) III. HISTORY OF PRESENT ILLNESS 1)
Enquire as to when patient was last entirely well? 2)
Presenting complaints a) Time (onset , duration ,
frequency , course) b) Place (site) c) Quality (character e.g.
of pain , composition of vomitus) d) Quantity (severity of
pain , amount of vomitus) e) Provocative / alleviative
factors / variations (diurnal or seasonal) f) Associated
symptoms g) Treatment if any 3) Systemic inquiry a)
General (weight loss , appetite) b) CVS (shortness of breath
on exertion , shortness of breath and sweaty on feeding,
cyanotic spells, squatting, fainting or syncope, cyanosis,
edema, chest pain/palpitations)
2. c) Respiratory system (sore throat, earache, cough,
wheeze, frequent chest infections, history of aspiration,
hemoptysis) d) Gastrointestinal system (abdominal pain,
vomiting, jaundice, diarrhea/constipation, blood in stools)
e) CNS (fits, syncope/dizziness, headache, visual problems,
numbness/unpleasant sensations, weakness/frequent
falls, incontinence) f) Genitourinary system (stream,
dysuria, frequency, nocturia/enuresis, incontinence,
hematuria) g) Rheumatological system (limp, joint
swelling, hair loss, skin rash, dry mouth/mouth ulcers, dry
or sore eyes, cold extremities) IV. BIRTH HISTORY
(Important in neonatal, genetic or developmental case)
ANTENATAL HISTORY (H/O PREGNANCY) 1) H & N status
(Health and nutritional status of mom during pregnancy)
2) Illness during pregnancy (HTN, DM, pre-eclampsia,
antepartum haemorrhage) 3) Infections during pregnancy
(rubella, UTIs, syphilis, T.B.) 4) Drugs (iron, multivitamin,
other drugs with dose, duration and at which time of
gestation) 5) X-ray (h/o irradiation in 1st trimester) 6) TT
(maternal vaccination against tetanus) 7) Past obstetric
(problems with previous pregnancies, stillbirths,
miscarriages, birth weight of previous children,
prematurity, blood transfusions) NATAL HISTORY (H/O
DELIVERY) 1) Place of delivery (hospital/home) 2)
Conducted by (dai/trained health visitor/doctor) 3)
Sterilization technique for instruments 4) Gestation time
(length) 5) Rupture time (time of rupture of membranes) 6)
Labour time (duration) 7) Presentation and type of delivery
(SVD, forceps, vacuum extraction or C-section) 8)
Sedation/analgesics during labour 9) Complications
(abnormal bleeding) POSTNATAL HISTORY 1) 1ST cry
(immediately/cyanosed/apneic) 2) Basic problems (need
for resuscitation, problem with respiration,
sucking/swallowing) 3) Birth weight 4) Birth injury 5)
Convulsions, cyanosis, jaundice, fever, rash 6) Procedures
(exchange transfusion, umbilical artery catheterization,
drugs)
3. V. FEEDING HISTORY (Significant in child < 2 years ,
anemic or malnourished) 1) Onset of feeding (a!er how
many hours) 2) Type of feed • Breast-fed (duration) • Bottle-
fed (at what age, composition of formula, amount,
frequency, dilution) 3) Supplements (vitamin, iron) 4)
Weaning (when, what, amount, frequency) 5) Current
diet/change in diet during illness VI. IMMUNIZATION (check
vaccination card * ) 1) Types of Vaccinations given 2) Age at
which started and by whom 3) Doses & adverse e"ects VII.
DEVELOPMENTAL HISTORY 1) Achieving age of various
milestones • Smiling • Ability to hold neck • Sit • Crawl •
Stand • Walk • Talk • Control of bladder and bowel 2)
Compared with normal for this age VIII. PAST HISTORY 1)
Significant illness in the past (esp. diarrhea, respiratory
infections, fevers, fits, jaundice) 2) History of similar
complaints in the past IX. PERSONAL HISTORY 1) Particular
habits of child 2) Details of class, school and interest in
studies 3) Any missed school attendance 4) Behavior of the
child at school and relationship with other children X.
DRUG HISTORY 1) Any medications used (frequency, dose,
adverse e"ects) 2) Allergy to any drug 3) H/o Mom drug
usage ** (in neonate or breast fed baby)
4. XI. FAMILY HISTORY (Important in chromosomal,
hereditary, infectious diseases) 1) Age of mother and
father? How long married? 2) Consanguinity *** 3) Parents’
health (present and past) 4) Siblings • Number • Age and
sex • Illness • Any death (cause if known or symptoms of
illness before death) • Stillbirths, miscarriages 5) Grand
parents’ health (esp. if living with family) 6) Health of
uncles, aunts and their children (if inherited disorder
suspected) 7) DO MAKE A FAMILY TREE *** XII. SOCIO-
ECONOMIC HISTORY 1) Parents’ education and occupation
2) Family income 3) House (made of, persons living, size) 4)
Cleanliness and general hygienic conditions 5) Source of
drinking water 6) Any pets at home

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