Pediatric History3

‫ عبد الرمحن اجلعكي‬.‫د‬

2222-2222

Written by Aya hamed

1
 Rheumatology history

H/O Joint swelling

Personal data
‫االسم‬
‫العمر‬
‫الجنس‬
‫السكن‬
‫الجنسية‬
Main complain analysis
Duration ( Acute – Chronic )
Site
Number of joint
Type ( Small – Large )
Course ( localized or migratory )
Aggravating factors
Relieving factors
Associated symptoms
Redness – hotness – skin rash –fever – wt loss – limitation of movement or limping – pain
H/O Trauma
Systemic review
Respiratory
H/O URTI – Cough – Dyspnea
GIT
Diarrhea – Constipation
GUS
Hematuria – frequency
Eyes ( redness ) uveitis
CNS
Headache – seizure
Blood
Bleeding – bone pain – pallor – lymphadenopathy
Past medical history
H/O Same illness
H/O Chronic disease as Rheumatologic disease
Drugs intake
H/O Surgery
Vaccination history
Developmental history
Delayed ? school performance
Family history
H/O Same illness
H/O blood disease or rheumatologic disease
Social history as before
Written by Aya Salem hamed ‫د عبد الرحمن الجعكي‬
 Child with limping
D/D of limping
Acute Chronic
Septic arthritis DDH
Transient synovitis JIA
Osteomyelitis SLE
Trauma Perth's disease
HSP
Personal data
‫االسم‬
‫العمر‬
‫الجنس‬
‫السكن‬
‫الجنسية‬
‫الباس عليه – اما رجل اليمين او اليسار‬
Duration ( < 6 wk - > 6 wk = JIA )
Onset ( sudden – gradual )
Course ( progressive or not )
Interfere with walking or not
Associated with pain or not
If associated with pain ask about ?
) Site – Duration – diurnal variation – increase with movement )
Joint ( Swelling + redness- pain at morning - which joint )
Ms atrophy
Associated symptoms
Fever – Rash – Wt loss – Change bowel habit
H/O Trauma
Systemic review
GIT
IBD – HSP
Respiratory
URTI
Blood
Leukemia
CNS
Endocrine
GUS
Past medical history
H/O Same illness
H/O Chronic disease as – SLE – JIA – IBD
Drugs uses
Surgical history
Nutritional history
Appetite ( good or poor )
Wt loss
Diet
Vaccination history up to data or not
Developmental history
Birth history
C/S – Breech – oligohydramnios
 Family history
F/H Same problem
F/H of any Autoimmune or blood disease as SCA
Social history
Live in flat or ground house
Smoking – Income
Written by Aya Salem hamed ‫د عبد الرحمن الجعكي‬
 Cvs history
H/O Shorteness of breath
D/D
Cardiac Respiratory Hematological
Heart failure According to age Anemia
Myocarditis Bronchial asthma Other causes
Bronchiolitis
Pneumonia
Other
Personal data
‫االسم‬
‫العمر‬
‫الجنس‬
‫السكن‬
‫الجنسية‬
Main complain analysis
Breathlessness
Duration
Onset
Diurnal variation
Severity

Increase with exercise

Ass with cyanosis
Aggravating factors
Feeding – Playing – Exercise
Ass with Sweating – Wt loss – Feeding difficulty – Cough - Wheeze – Fever – Syncope

If old child ( chest pain – Palpitation – Syncope – Odem )

Systemic review
Respiratory CNS MSK Blood
Cough Seizure Joint pain Pallor
Wheeze LOC Joint swelling Bleeding
Chocking Chorea
Recurrent chest Abnormal
infection movement
H/O URTI
Past medical history
H/O Same illness
H/O Chronic disease - cardiac disease CHD – Respiratory disease as asthma – Blood disease
H/O INV As Echo
H/O Drugs use
H/O Oparation
Birth history
Antenatal Natal Postnatal
Skin rash NVD- C/S ICU admission
TORCH Term – preterm Cyanosis
 Fever Wt at birth CHD
MV
Nutritional history
Feeding as before – Wt gain
Vaccination history
Developmental history
Family history
F/H of same illness
F/H of cardiac disease - Echo ?
Respiratory disease Atopy
Sudden death
Consanguinity
Family members
Social history
Income - Smoking - Housing – Ventilation
Written by Aya Hamed ‫د عبدالرحمن الجعكي‬
 History of Palpitation And Chest pain
D/D of Palpitation D/D of chest pain
Cardiac ( Arrhythmia ) Cardiac
Blood ( Anemia ) Respiratory
Drugs ( B2 agonist ) Musculoskeletal
Endocrine ( Thyrotoxicosis ) Traumatic
Other ( psychological )
Personal data
‫االسم‬
‫العمر‬
‫الجنس‬
‫السكن‬
‫الجنسية‬
Main complain analysis
Palpitation Chest pain
Onset ( Sudden or Gradual ) Site
Duration ( Minutes or hours ) Onset
Aggravating ( stress - Exercise ) Character
Reliving ( Rest – Medication ) Duration
If recurrent or not Aggravating factors
Associated symptoms Reliving factor
Dizziness
Chest pain
Breathlessness
LOC – Syncope

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

History of pallor and fatigability

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

‫البأس يا ام محمد الحظت ابني عنده شحوب في الوجه‬

1 Onset ( sudden – gradual)

2 Duration ( days _ wks_months )

3 Site ) ‫(الجسم كله – العيون –الوجه‬

4 Course ( progressive – regressive – stationary )

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

To exclude leukemia and aplastic anemia Ask about ?

Wt loss - fever -bone pain -joint swellings -neck swelling
Bruises _skin rash _ bleeding
Systemic review
GIT
Vomiting _ diarrhea_ constipation _ abd distention( malabsorpsion)
H/o melena or bleeding per rectum
Respiratory
H/o common cold_ exercise intolerance- cyanosis
CNS
Dizziness_ headache _decrease concentration_ seizure
MKS
Joint swelling or pain
 Past medical history
H/o same illness _ H/o any chronic disease ex_ blood disease
H/o surgery –H/o blood transfusion
Drug intake ( iron therapy)
Birth history
Term or preterm
Nutritional history
Feeding 1_ type 2_ amount 3- type of formula 4-Is use special formula
Weaning ? 1_ onset 2- type of diet 3_ food allergy
H/o pica _ appetite _ wt loss
Family history
F/o same illness -blood disease ex _hemolytic anemia
H/o Frequent blood transfusion
Social history
Housing
Income –Education level of mother and father
Water supply

0202 ‫د عبد الرحمن الجعكي‬

 History of Bruises and Ecchymosis
D/D
1-Idiopathic Thrombocytopenic Purpura
2-Other causes of low PLT ex (HUS)
3-Leukemia
4-Aplastic anemia
5-Coagulation Disorders ( hemophilia _VWD)
6-Child abuse
7-Traumatic
8-Vaculities ( HSP)
Personal data
‫االسم ثالثي‬
‫العمر‬
‫الجنس‬
‫السكن‬
‫الجنسية‬
Main complain analysis
1-Onset (Sudden_ gradual)
2-Duration
3-Site
4-Number ( single or multiple )
5-Color
6-Blanching or not
7- H/o trauma
Associated Symptoms
1-Bleeding ex 1- Epistaxis 2- gum bleeding 3- bleeding from any orifice
2-Hematemesis
3-Hematuria
4-H/o bleeding per rectum or melena
5-H/o jaundice
6- To exclude leukemia and aplastic anemia Ask about ?
Wt loss - fever -bone pain -joint swellings -neck swelling
Bruises _skin rash _ bleeding
Systemic review
GIT
Vomiting _ diarrhea_ constipation _ abd distention
H/o melena or bleeding per rectum
Respiratory
H/o common cold URTI = ITP _ h/o breathlessness
MKS
Joint swelling or pain
Renal
h/o hematuria and dysuria
CNS
Seizure- headache- photophobia

Past medical history

H/o same illness _ H/o any chronic disease ex_ blood disease
H/o surgery –H/o blood transfusion
Drug intake ( iron therapy)
H/o bleeding befor - post surgery- male post circumcision
 At site of vaccination- at birth bleeding from umbilical stump

Family history
F/o same illness -blood disease ex _hemolytic anemia
H/o Frequent blood transfusion
Consanguinity
Social history
Housing- income- education - divorcing

History bleeding per nose or per gum

personal data
‫الجنسية‬- ‫السكن‬- ‫الجنس‬- ‫العمر‬- ‫االسم‬
Main complain analysis
Onset
Duration
Amount( Is there clots )
Frequency

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

Rest of the steps as before

 Child with bone pain
(Known case 0f sickle cells anemia)

With leg pain and fever

Personal data
‫*أالسم الثالثي‬
‫*العمر‬
‫*الجنس‬
‫*السكن‬
‫*الجنسية‬
Main complain analysis

-Duration

-Onset

-Site

-Severity

Is interfere With sleeping

Is interfere With playing
-Limping
-Not relieved by analgesia
-Diurnal variation
-Aggravating factor
-Reliving factor(Rest –Analgesia)
-Redness and swelling
-Fever
-H\o skin rash-Bruises-Ecchymosis
-H\o trauma
-Joint swelling
Systemic review:-
Respiratory
)‫ كحة – زرقة – ألم في الصدر‬-‫(دهشة‬
Cvs
(Palpitation- chest pain)
Cns
(Seizure- headache- Loc - Photophobia)
GIT
Vomiting – wt loss- diarrhea- constipation –abd distension-abd pain(jaundice=hemolysis)
Acute abdominal crisis.
Renal
Hematuria-Dysuria
Blood
Pallor- bruises-
Bleeding from any site
Joint swelling
Past medical history
Kown case of sickle cells anemia
‫ قداش ليه‬-1
‫ خاش مستشفي ؟كم مره؟ عالش خاش عناية ؟‬-0
‫ بانتظام؟‬.‫ المتابعة‬-2
)penicillin –vulturine- panadol- hydroxyuaria- folic acid( ‫ األدوية‬-4
‫زيادة دم؟قداش مره؟ الفصيلة؟‬-5
‫؟‬Hb ‫ أخر‬-6
‫ العملية الجراحية؟‬-7
Vaccination history
Up to date or not
Special vaccine
Hib –pneumococcal vaccine- meningococcal
Developmental history
School performance
School absence
Familg history
Same illness in the family
F \o of consanguinity
Number of family
Social history
Housing
Income
Educational level of parents
Financial support
Social impact of disease
 Case with neck swelling
Personal data
‫االسم‬
‫العمر‬
‫السكن‬
‫الجنس‬
‫الجنسية‬
Main complain analysis
Duration
Onset
Course
Site
Associated with pain or not
Number – Size
Associated with redness or discharge or not
Swelling elsewhere
Associated symptoms
Fever
Wt loss – night sweating
Poor appetite
Cough – Dyspnea
Skin rash and joint swelling
Swelling elsewhere
Systemic review
Respiratory system
H/O URTI
Sore throat
Ear discharge
CVS
Cyanosis
Palpitation
Renal
Dysuria
Color and smell of urine
GIT
Dysphagia
Jaundice
Abd pain
Vomiting
Melena
Blood
Pallor

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

3-CKD – RTA – FANCONI SYNDROME

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

GUR – dysuria – hematuria ( UTI )

Past medical history
H/O Chronic disease as – GERD – CHD
H/O Admission
H/O Drugs use
H/O Surgery
Developmental history
Ok or delayed ?
Vaccination history
Up to date or not
Birth hisrory
Antenatal H/O TORSH - Natal H/O HIE – Postnatal- IUGR
Family history
H/O FTT in the family
Family history of any chronic disease

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
ORGANICGIT(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