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3 Pediatric history 2023#3 د عبدالرحمن الجعكي
3 Pediatric history 2023#3 د عبدالرحمن الجعكي
1
Rheumatology history
Sweating
Pallor – Fatigability
Cyanosis
Cough
Systemic review
Respiratory GIT Endocrine MSK Skin CNS
Cough Diarrhea Thyroid Joint pain Skin rash Headache
swelling and swelling
Wheeze Nausea Dizziness
Breathlessness Vomiting
Cyanosis Abdominal
distension
Past medical history
H/O Same illness
H/O Heart disease – Echo – ECG ?
H/O Respiratory disease
H/O Blood disease
H/O Admission
Drug use
H/O Trauma
Nutritional history
Vaccination history
Developmental history
Family history
F/H Of Same illness
F/H Heart disease
F/H of sudden death - Arrhythmia
F/H Of Atopy
F/H of respiratory disease
Social history
Housing – Smoking – Income
Written by Aya Hamed د عبدالرحمن الجعكي
H/O Cyanosis ( blue child )
Personal data
االسم
العمر
الجنس
السكن
الجنسية
Main complain analysis
Duration
Onset
Course
Site
Association with
Breathlessness ( fast breathing )
Irritability
Abnormal movement
Deteriorated – LOC
Vomiting – chocking
Systemic review
CVS
H/O FTT - Cyanosis before – difficulty in feeding
Respiratory
Cough – breathlessness - abnormal sound
CNS
Headache
GUS
Dysuria
GIT
Wt gain – change in bowel habit
Endocrine
As before
Past medical history
H/O Similar attack – H/O Admission
H/O any chronic disease or problem
- Exercise intolerance
-Chronic respiratory disease – recurrent chest infection
- Epilepsy
- H/O Surgery ( cardiac surgery )
-H/O Drugs intake
-H/O Blood transfusion
Birth history
H/O neonatal admission and MV
H/O Cyanosis in neonatal period
H/O Drugs ingestion
Nutritional history as before
Vaccination history as before
Family history
F/H OF Same illness
F/H Of cardiac disease in family
F/H of sudden death in family
Developmental and Social history as before
Blood history
D/D
1-Anemia (IDA)
2-Other anemia hemolytic anemia with jaundice
3- Aplastic anemia
4-Leukemia
Personal Data
االسم ثالثي
العمر
الجنس
السكن
الجنسية
5 Association symptoms
Fatigability
ناشط او الحظته فاشل ؟ قداش ليه الفشل ؟ هل بدا مع الشحوب ؟ هل الفشل طول اليوم او يلعب و في الليل يفشل ؟
هل مأثر على المدرسة ؟ هل مأثر على اللعب ؟ هل مأثر على تركيزه في القراية ؟ هل و هو مقعمز فاشل او لما يتحرك ؟
Breathlessness
هل يدهش عند المجهود ؟
Is ass with jaundice = hemolytic anemia
Family history
F/o same illness -blood disease ex _hemolytic anemia
H/o Frequent blood transfusion
Consanguinity
Social history
Housing- income- education - divorcing
Color
H/o trauma
Bleeding from other site ( hematemesis – hematuria- hematochezia-melena)
H/o bruises or ecchymosis
H/o purpuric rash
H/o joint swelling
H/o pallor and fatigability due to bleeding
H/o loss of consciousness
Wt loss - fever -bone pain -joint swellings -neck swelling
-Duration
-Onset
-Site
-Severity
Bruises
Endocrine
Tremor
FTT
Past medical history
H/O Same illness before
H/O Chronic disease or Admission – Recurrent infection
H/O Drugs intake ( Antiepileptic)
H/O Surgery – blood transfusion
Nutritional history
According to Age < 2 years ( breast – bottle – weaning )
Older child
Vaccination history
Up to data or not
Developmental history
AS before
Birth history
If < 2 years
Family history
H/O Same illness in the family
H/O any chronic disease ( chronic cough = TB )
Social history
Income – Animal contact
Smoking – flat or ground house
Source of water – H/O Travel
Endocrine history
H\O Polyuria and Polydepsia
D\D
1-Dm
2-DI
4- increase Ca – decrease K
5-Psychogenic
DM
Newly Diagnosis Known Case
Polyuria and polydipsia Abdominal pain
Abdominal pain and vomiting Vomiting
Personal data
األسم الثالثي
العمر
السكن
الجنس
الجنسية
Main Complain analysis
هل معاها حاجة ثانية؟, ويتبول هلبة, أبني يشرب هلبه. ال بأس يا أم أحمد
Polyuria Polydipsia
-Duration -Duration
-Amount -Amount of water (type of fluid )
-Frequency (at night >2times) - Diurnal variation
-Color of urine
-Dysuria
Associated Symptoms :-
-Wt Loss
-Abdominal Pain (DKA)
-Fever
-Appetite
-Rapid breathing (DKA)
- Conscious level
-Activity
-Sings and Symptoms of dehydration
) يبكي بدون دموع, (هل عيونه خشو
Systemic review
Respiratory
*Rapid breathing
*H\o URTI
Git
Diarrhea – constipation – abdominal distension - Wt
Endocrine
*Thyroid gland swelling
*Hypothyroidism
Cns
*Seizure
*L.O.C
*Vision
*Tremor
Skin
*Hypo or hyper pigmentation
*sweating
*Vitilligo
PMH
*H\o same illness
*H\o Dm-
Feeding history ( Nutritional history )
*Diet
*Carb Count
*Special diet
Birth History
Prenatal
*Follow-up
*H\o Dm
*H\o Torch
Natal
NVD or c\s
Birth wt
Term or preterm
Postnatal
Post natal complication
Bireast feeding ( decrease incidence of type 1 dm )
Vaccination history
Up to date
Special vaccine ( flu vaccine and covid )
Developmental history
School performance
School absence
Exercises intolerance
Family history
F\H of DM
F\H Of celiac disease
F\H Of thyroid disease
Social history
Housing
Smoking
Financial support
Impact of disease
Animal contact
If known case of DM
Main complain ( Abdominal pain – Vomiting )
قداش ليه عنده السكري ؟
يتابع او ال ؟
؟NICU ؟DKA خاش مستشفى ؟ قداش مرة ؟ عالش
)syringe or pen( العالج ؟ انسولين ؟ الجرعة قداش ؟ الطريقة
طريقة الحقن ؟ المكان ؟ تغير المكان الضرب ؟
Is controlled or not ?
عندك جهاز قياس السكر ؟
مسجلة القراءات ؟
اخر تحليل تراكمي كم ؟
تحليل الغدة الدرقية ؟
تحليل حساسية االمعاء ؟
Main complain analysis
Abdominal pain Vomiting
Duration Duration
Site Frequency
Radiation Vomitus
Food – bile – blood – amount – projectile
Character of pain Associated with
Severty 1-Abdominal pain
Interfere with school
Interfere with sleeping
Interfere with playing
Not response to analgesic
0-Change in bowl habit
2-Wt loss
4-Polyuria - Polydipsia
5-Rapid breathing
6-Nausea
7-L O C
Systemic review
GIT
Diarrhea – constipation – abdominal distension – Wt
CNS
*Seizure
*L.O.C
*Vision
*Tremor
CVS
Exercises intolerance
Endocrine – puberty
PMH
*H\o same illness
*H\o Dm-
Feeding history
Nutritional
*Diet
*Carb Count
*Special diet
Birth History
Prenatal
*Follow-up
*H\o Dm
*H\o Torch
Natal
NVD or c\s
Birth wt
Term or preterm
Postnatal
Post natal complication
Breast feeding ( decrease incidence of type 1 DM)
Vaccination history
Up to date
Special vaccine ( flu vaccine and covid )
Developmental history
School performance
School absence
Exercises intolerance
Family history
F\H of DM
F\H Of celiac disease
F\H Of thyroid disease
Social history
Housing
Smoking
Fanincial support
Impact of disease
Animal contact
History of short stature
Personal data
االسم الثالثي
العمر
السكن
الجنس
الجنسية
Main complain analysis
الباس يا ام
ابني الحظته قصير
كيف عرفته قصير ؟ هل بالمقارنة مع االطفال في نفس العمر ؟
Onset
From birth = IUGR
Early = cystic fibrosis
Frist years = GH
Latter = celiac and IBD
What is type of short stature ?
D/D
Familial SS Endocrine
Constitutional SS Dismorphic
Chronic disease
Malnutrition
IUGR
Psychological
Drugs
Associated with wt loss( malnutrition –chronic disease ) or obesity ( endocrine ) ?
Associated with any chronic disease ?
Systemic review
GIT
Chronic diarrhea –constipation – bloody diarrhea – abdominal distension – jaundice
Respiratory
Chronic cough – breathlessness – cystic fibrosis
CNS
Chronic headache – visual defect
Endocrine
Neck swelling –hot and cold intolerance – polydipsia- polyuria – activity – Wt
Renal
Color of urine – amount – edema
MSK
Joint swelling and pain – deformity or fracture
CVS
Cyanosis – edema – breathlessness
Past medical history
H/O any chronic disease as asthma c f – celiac – DM – IBD – CKD
H/o Admission – H/O recurrent infection
H/O surgery – H/O drugs ( steroid )
Birth history
Antenatal H/O fever – skin rash ( TORSH ) Drugs uses as irradiation
Natal - Wt – GA – term or preterm – NVD – C/S
Postnatal – H/o NICU care or any INV done
Developmental history
Gross – Fine – Vision and speech – Social
School performance - Puberty in old
Family history
F/H OF SS
F/H Of delayed puberty
F/H Of any genetic disorder or chronic disease
Vaccination history
Up to date or not
Nutritional history
Food type and amount of calorie
Any special diet
Social history
Income – psychosocial problem – car – education level of parents
Cerebral Palsy and developmental history
Cerebral Palsy
New case
Personal data
االسم
العمر
السكن
الجنس
الجنسية
Main complain
Age of onset
Analysis of main complain
Developmental history
Gross
Fine
Vision
Hearing
Speech
Social
Systemic review
GIT Respiratory CNS Gus Skin MSK
Feeding Cough Spasticity
FTT Aspiration Seizure
Constipation Chest Deformity
infection
Vomiting Fever Abnormal
movement
Small or
Large head
Past medical history
H/O Same illness
Any chronic disease
Drugs ( Anti epileptic )
Admission – ICU – previous INV
H/O Trauma or CNS infection
Birth history
Antenatal Natal Post natal
Follow up NVD – C/S Jaundice
TORCH Term – Preterm NICU Admission
DM Wt CNS infection
Crying Hypoglycemia
Drugs
Family history
H/O Same illness - Twins – Developmental delay
Epilepsy – Death – Consanguinity
Feeding history
Association symptoms
Vomiting – regurgitation – chocking –( GERD )
Diarrhea ( malabsorption )
Constipation
Abdominal distension
Systemic review
Respiratory system Wheeze – breathlessness – recurrent infection
CVS – sweating – cyanosis
Skin – eczema
Blood – pallor – bruises
Social history
-Income – social status
-Economic support
-Nutritional education of mother
- H/O animal contact – travel
If known case of Cerebral Palsy
Personal data
االسم
العمر
السكن
الجنس
الجنسية
Main complain analysis
Systemic review ( comorbidities and problems )
Respiratory GIT CNS MSK
Aspiration Feeding Seizure Mobility
Chest infection Wt Activity
Constipation Vision and hearing
Past medical history
H/O same illness
Known case of CP
( Onset – Duration – Follow up – Admission ( Word or ICU ) Why ? – Drugs ( dose – S/E – INV
done ( EEG – CT brain scan )
Physiotherapy – Speech – Vision
H/O Surgery
Developmental history
Nutritional history
Birth history
Family history
F/O Same illness
D Delay
Consanguinity
Death
Vaccination history
Social history
Housing
Income
Care – Social Support
Written by Aya Salem Hamed د عبد الرحمن الجعكي
Developmental delay history
D/D Global Delay
1-Birth Asphyxia –CP
2-TORCH
3-Chromosomal
4-Hypo thyroidism
5-IEM
Personal Data
االسم – العمر – السكن – الجنس
Main complain analysis
Developmental history
Developmental delay
Age of onset ?
Gross motor ( head control – roll over – sit – crawl – creep – stand – walk – run - up stair –
kick a ball )
Vision ( V A- Squint – can pick up – reach well for toys – fix and follow )
Hearing ( Response to his name and words – Turn immediately to your voice – Smile and
turn his head and eyes to your voice - Startle to sudden noise )
fine motor ( hold pen + scribble – build a blocks – tower – hold rattles transfer from
hand to hand – mouthing )
Speech and language ( what exactly can say ? ( mama – baba - 2 words – bubble – startle –
response to own name – known color )
Associated symptoms
Seizures – Spasticity – deafness
Feeding problems – Wt gain – Aspiration – Constipation
Dimorphic features - head size
Neurocutaneouse manifestation
Systemic review
Fever – Cough – Vomiting – Color of urine
Past medical history
H/O Admission
H/O Surgery
H/O Trauma
Previous investigation ( CT scan – MRI – EEG –Metabolic inv )
Drugs
Birth history
Antenatal Natal Postnatal
Previous abortion Preterm – Term Admission
TORCH Wt Neonatal jaundice
Drugs NVD – C/S Hypoglycemia
Follow up Crying Sepsis
Head trauma ( IC he )
MV
Family history
F/H Same illness
F/H Consanguinity
F/H Genetic disease – developmental delay
F/H Epilepsy – Death
Feeding history
Feeding type – Special diet – Aspiration – Wt gain
Immunization up to date
Social history
( Housing – Social support – Income )
Written by Aya Salem Hamed د عبدالرحمن الجعكي
failure to thrive history
History of failure to gain Wt ( FTT )
DD
ORGANICGIT(GERD-MALAPSORPTION )
RESPIRATORY(CYSTIC FIBROSIS )
RENAL(RENAL TUBULAR ACIDOSIS –FANCONI –CKD )
CVS (CONGENITAL HEART DISEASE –HF)
NUTRITIONAL (PEM)
NONORGANIC (POVERTY –SOCIAL DEPRIVATION –NEGLECT )
Personal data
االسم
العمر
الجنس
السكن
الجنسية
Main complain
Failure to gain Wt
Onset - Science birth – In Specific period
Duration
كيف الحظتي الوزن ينقص و معاش يزيد – هل بالوزن او المالبس او كيف ؟
الوزن بس او حتى الطول ؟
Ask about feeding in details
Good or poor feeding
Bottle feeding Breast feeding
قداش رقم قداش مرة
قداش مرة يكفي فيه او يقعد يعيط
كيفية التحضير كيفية الرضاعة
التعقيم
نوع الحليب
حليب خاص
تعقيم الماء
If more than 4 m or = 4 m ask about weaning and special type of food
Association symptoms
Vomiting – regurgitation – chocking –( GERD )
Diarrhea ( malabsorption )
Constipation
Abdominal distension
Systemic review
Respiratory system Wheeze – breathlessness – recurrent infection
CVS – sweating – cyanosis
Skin – eczema
Blood – pallor – bruises FATIGABILITY
GUR – dysuria – hematuria ( UTI )
Past medical history
H/O Chronic disease as – GERD – CHD
H/O Admission R ECURRENT INFECTION
H/O Drugs use
H/O Surgery
Developmental history
Ok or delayed ?
Vaccination history
Up to date or not
Birth history
Antenatal H/O TORSH - Natal H/O HIE – Postnatal- IUGR
Family history
H/O FTT in the family
Family history of any chronic disease
H/O CONSAGIUNITY
Social history
-Income – social status
-Economic support
-Nutritional education of mother
- H/O animal contact – travel
Written by Aya hamed د عبد الرحمن الجعكي
2023