Pediatric history pdf - مجموعة طلاب

Pediatric history

#Identification



Name of baby (triple name)



Age and date of birth



Gender



Blood group



Source of history (mother – father – grandmother)



Occupation of parents



Residence of parents



Religion of parents

#Date of admission

#Date of examination

#Chief compliant



Mention the main reason that brings the patient to the hospital (up to 3 chief
compliant)



Duration of chief compliant

#History of present illness



Last time the patient was well



The story (take it from the source like the mother, ask her to tell you the full story
then summarize it and write it in her words)



Analysis of the symptoms



Complete the same system



Relevant systems (ask about any system related to the involved system)



Routine questions: always ask about (fever, sweating, urine output, feeding, activity,
sleep, weight loss)



Ask about attention to private doctor or primary health centers PHC (ask about
investigations, treatment, improvement or not)



Admission (ask about investigations, treatment, improvement or not)



Any new event that may occur during hospitalization ((worsening of baby condition
ask about sleep + activity (smile/fatigue) + feeding all will decreased ))



Outcome (the condition of patient at the moment of taking history)

((convert these points to story and write it))

#Systems review

(questions here depend on the age of baby)



GIT  abdominal pain, diarrhea, constipation, vomiting, hematemesis, melena,
jaundice, nausea and loss of appetite (the last two describe as poor feeding)



Respiratory  dyspnea, noisy breathing, cough, hemoptysis, sputum



CVS  dyspnea, palpitation (the mother could feel palpitation of her baby), cyanosis



Genitourinary  color and amount of urine, hematuria, pyuria, dysuria, frequency,
any abnormality in the genetalia



Nervous system  headache, convulsions, abnormal movements



Loco-motor  joint pain and stiffness, joint swelling, waking, abnormal movements,
restricted movements



Hematology  epistaxis, bruises, patichae



Skin  dryness, discoloration, pigments, itching, rash, lump, hair and nail changes

#Pre-natal (Ante-natal)



ANC (does the mother attend regular visits to private doctor or PHC)



Disease of mother during pregnancy (infections like Toxoplasma-HIV-Rubella-
Cytomegalovirus-Chickenpox-Hepatitis --- TORCH infection appear as fever + skin rash
+ joint swelling --- other diseases like D.M and hypertension and anemia)



Drugs taken during pregnancy



Exposure to radiation during pregnancy



Smoking



Bleeding



Previous abortion or neonatal death



Admission to hospital for any reason



Vaccine



Number of child

#Natal



Place of delivery (at home or hospital)



Type of delivery (vaginal or caesarian section CS) if CS what is the indication? Elective
or emergency?



Duration of delivery (normal or prolonged)



Any complication during labor



Instrument use in the delivery



Gestational age (pre-term or term or post-date or post-term)



Weight of the baby (normal AGA , Small SGA , Large LGA)

#Post-natal

(first 28 days of life)



Immediate crying



Time of discharge from the hospital (24 hours – 48 – more)



NICU admission



When the baby passed urine (within first 24 hours) and meconium (the first stool)
(within first 48 hours)



Movement



Neonatal jaundice, Cyanosis (fetal distress), Fit, bleeding



Baby developed other diseases? Treatment?

#Past-medical history



Previous similar disease



Previous admissions



Chronic diseases



Previous infections (measles, others)



Blood transfusion

#Past-surgical



Previous operations (indication, type, outcome)



Circumcision in male and ear piercing in female (at which age, any complications)



Hospitalization

#Drug history



Drug taking by mother (chronic use)



Drug taking by baby (chronic use)



Allergy to drug and other substances

#Feeding history

1- Breast feeding



Way of feeding (using both right and left breast each feeding time)



Regular (at least every 3 hours) or on demand



Any problem with feeding (large nipple, others)

2- Bottle feeding



Way of feeding



Way of preparation



Type of formula use (lactose free, soy milk formula, others)



Way of sterilization of the bottle (boiling, Washing, brushing)



Number of bottles



Number of feeding



Regular (at least every 3 hours) or on demand



Any problem occur after bottle feeding (diarrhea, others)



Put the bottle in freeze for cooling

3- Mixed feeding (breast and bottle feeding)
4- Semi-solid or solid food



At which time given



Type



Any problem occur after this feeding

5- Weaning: at which age milk was taken off his diet
6- Pica: Ask if the child eat soil, wood or other things (caused by iron deficiency anemia –

Ca deficiency – lead poising)

#Immunization history



Take the vaccines on regular Iraqi schedule or not?



On national immunization day only?



Type of vaccine



At which age?



Any complications (fever, pain, convulsion, rash, excessive crying) pertussis vaccine
cause convulsion – shock



Time of last vaccine



Notes: RV not give to baby after 3 and 8 months of age / BCG not give to baby after 1
year of age / BCG should return if the scar ( )ندبةnot appear

Age

VACCINE

24 hours after birth BCG, HBV , OPV
2 months

DTP-HepB-Hib, OPV, RV

4 months

DTP-Hib, OPV, RV

6 months

DTP-HepB-Hib, OPV, RV

9 months

Measles, Vit.A

15 months

MMR

18 months

DTP-Hib, OPV, Vit.A

4-6 years

DTP, MMR, OPV

Name

In Arabic

Type

Route

BCG

بي سي جي

Live attenuated TB bacteria

HBV

إالتهاب الكبد

الفيروسي ب

Inactivated hepatitis B virus

OPV

شلل األطفال فموي

Live attenuated Polio virus

Oral

الفايروس العجلي

Live attenuated Rotavirus

Oral

Measles

الحصبة المنفردة

Live attenuated measles virus

MMR

الحصبة المختلطة

Live attenuated, mumps, rubella viruses SC

DTP

اللقاح الثالثي

Diphtheria and Tetanus Toxoid +
inactivated pertussis bacteria

DTP-Hib

اللقاح الرباعي

DTP + Inactivated Influenza virus

DTP-HepB-Hib

اللقاح الخماسي

DTP + Inactivated Influenza virus +
Inactivated hepatitis B virus

#Developmental



Gross motor (sit, stand, walk) or crawl



Fine motor (Grasp, move object from hand to hand, etc.)



Social (smile, laugh, etc.)



speech



vision



hearing

#Family history



health of parents, brothers and sisters



family history of same illness



family history of chronic disease or infectious disease



family history of unexplained death



order of baby in the family



age of the baby before or after him



any illness in the family

#Social history



rural or urban



source of water



income



level of education and occupation of parents



crowding index  (number of persons/number of rooms)  below 3 is normal and
above 3 is crowding



any domestic animals



ventilation



smoking



sewage disposal

#Obstetrical and gynecological history



for girls because pediatric age up to 18 years