HISTORY TAKING IN PEDIATRICS

Dr. C.S. Balachandran, Professor,

Dr. Chintu Oommen
Rajah Muthiah Medical College & Hospital
Annamalai University

IDENTIFICATION

Name
Informant
Age
Reliability
Sex
Address

ORDER OF HISTORY TAKING

Chief complaints
Chronological order

History of Presenting illness

Past history
Antenatal history
I, II, III trimester

Natal history
Post natal history
Developmental history

Immunization history
Diet history
Family history
Socio economic history
Allergic history
Treatment history
Contact history

CHIEF COMPLAINTS

Fever
Cough
Abdominal pain
Diarrhoea
Convulsions
Vomiting

HISTORY OF PRESENTING ILLNESS

Fever

Duration
Onset
High grade or low grade
Chills and rigors
Evening rise of temperature
Continuous or intermittent

COUGH

Duration
Onset
Character
Diurnal variation
Associated with sputum

Colour
Quantity
Foul smelling
Blood stained

DIARRHOEA AND VOMITING

Duration
Onset
Frequency of diarrhoea and vomiting
Diarrhoea

Consistency
Smell
Colour
Blood & mucous
Perianal excoriation

Vomiting
Contents
Blood stained
Projectile or non projectile

ABDOMINAL PAIN

Site
Type
Severity
Radiating or non radiating
Aggravating factors
Relieving factors

CONVULSIONS

Generalized or localized
H/o Aura
Duration
Associated with fever or vomiting
Bowel and bladder incontinence present or not
H/o LOC, Headache
Post-ictal drowsiness

PAST HISTORY
Similar illness in past
Any significant disease in the past
Any illness like measles, tuberculosis, asthma
jaundice
Contact present with any disease or not
Previous history of hospitalization
H/o Medications
Surgical History

BIRTH HISTORY

Previous obstetric history

Normal delivery or not
Complications
Weight of the baby
Deformity present or not
H/o Complications during pregnancy

FIRST TRIMESTER
Any antenatal check ups (Booked Case)
Last menstrual period date
Fever with rash with painful post auricular
lymphadenopathy
History of handling of pets present or not
H/o Exposure to drugs / Irradiation
Weight gained by mother

SECOND TRIMESTER

Quickening felt or not

TT injection given or not
Iron and folic acid tablets
USG done or not
Mother had PIH or diabetic mellitus
Bleeding / Leaking PV
Antenatal checkup

THIRD TRIMESTER

Bleeding per vaginum

Any infections
USG done or not
H/o of drug intake
H/o of exposure to radiation

NATAL HISTORY

Child term, preterm or post term

Born hospital or home
Mode of Delivery
Child cried immediately after birth or not
Child passed meconium or not
Any resuscitation done or not
Prolongation of labour
Birth weight

POST NATAL HISTORY

Child developed icterus or cyanosis

Child breast fed or on artificial feeds
History of convulsions
Weaning foods
Which day umbilical cord fell down
Feeding problems

DEVELOPMENTAL HISTORY

Gross motor head holding, rolling over

Fine motor palmar grasp
Language mono syllabus, bi syllabus
Personal and social recognizing mother

IMMUNIZATION HISTORY
AGE

VACCINE

Birth-15 days

BCG,OPV zero dose,

Hepatitis B Vaccine 1st dose

6 weeks-8 weeks

DPT 1st dose,OPV 1st dose,

Hepatitis B Vaccine 2nd dose

10 weeks - 12 weeks

DPT 2nd dose,OPV 2nd dose.

14 weeks - 16 weeks

DPT 3rd dose,OPV 3rd dose

6 months - 9 months

Hepatitis B Vaccine 3rd dose

9 months (Completed)

OPV- 4th dose,Measles vaccine.

15 months - 18 months

MMR (Measles, Mumps, Rubella)

DPT 1st Booster dose,
OPV 1st Booster dose.

5 years

DPT 2nd Booster, OPV 2nd Booster

10 years

TT 3rd Booster dose,

Hepatitis B Vaccine Booster dose.

15 16 years

TT 4th Booster dose.

Birth 15 days

BCG + OPV (zero dose) Hepatitis B 1st dose

6-8 weeks

OPV1 + DPT1 + Hepatitis B 2nd dose + Hib 1st dose (DPT

+ Hib can be given as a combined vaccine)

10-12 weeks

OPV2 + DPT2 + Hib 2nd dose

14-16 weeks

OPV3 + DPT3 + Hib 3rd dose

(DPT+ Hib can be given as combined vaccines)

6-9 months

Hepatitis B 3rd dose

9 mon

Measles vaccines

15-18 months

MMR vaccine,1st booster of OPV + DPT

Booster of Hib vaccine, Varicella vaccine

2 yrs

Typhoid vaccine & repeat every 3-5 years

Hepatitis A vaccine followed by 2nd dose at 6-12 months
following 1st dose

4-6 years

2nd booster of OPV + DPT

10 years

Tetanus Toxoid

16 years

Tetanus Toxoid

DIETARY HISTORY
Calorie requirement for a child
1-10 kg 100 Kcal/ kg/day
11-20 kg 50 Kcal/ kg/day
> 20 kg 20 Kcal/ kg/day

Protein requirement for a child

1.5 gram / kg / day

Simple formula
Till one year age 1000 K.cal
Add 100 K.cal every year

CALORIFIC VALUES OF COMMONLY

USED FOOD STUFFS
Cereals
1 cup of rice
1 chappatti
Pulses
1 cup of cooked dal
Milk / 100 ml
Human mil
Cows milk
Fats
Ghee 1 tsp
Butter 100 gms
Non veg
1 egg
Fish 100 grams
Mutton 100 grams

Protein
2gms
2gms

Calories
100 cals
50 cals

10gms

300 cals

1.1gms
3.3gms

65 cal
67 cal

45 cal
730 cal

6gms
20gms
22gms

60-70 cals
100 cals
118 cals

FAMILY HISTORY

Age of parent at marriage

H/o Consanguinity
Number of siblings
Abortions or infant deaths
History of contact
Nuclear or joint family
H/o Mental retardation, diabetes mellitus

SOCIO ECONOMIC HISTORY

Number of persons living

Occupation
Education
Housing conditions
Type of water for drinking, cooking
Income
Per capita income = Total income of family / No. of
family members

Kuppuswami
Scale for SES

ALLERGIC HISTORY
Allergy to drugs
Allergy to food items like
Egg
Milk
Meat

CONTACT HISTORY
Any history of contact with disease like
Measles
Whooping cough
Tuberculosis

Thank you