history paper sheet of pediatric pdf - طلاب المرحلة الخامسة

Fifth stage

Practical pediatric

كتابة الطالب

د.ندى

19/10/2015

History sheet paper

Firstly take the general info



Name:-



Age:-



Sex:-



Adress:



Source of Hx :-



Date of Admission:-



Date of exam:-



Religion:-

C.C:-not more than 2 complaints.

H.P.I:-you 'll talk about the system that is affected.

Review of systems:-

1)Respiratory :-



Cough





Sputum





Hemoptysis





Shortness of breath





Tachypnea





Cyanosis





Nasal discharge:-always ask unilateral or bilateral,,color,,has smell ?

2)Git:-



Salivation:-



Abdominal distension:-



Vomiting:-



Change in bowel motion:-



Regurgitation:-



Poor feeding:-

3)Urinary system:-



Color of urine:-



Crying on Urination:-



Frequency:-

4)Cns:-



Consciousness:-



Irritability:-



Any abnormal movement//posture.?



Tremor:-

5)locomotor system:-



Limitation of movement:-



Joint swelling:-

6)skin:-



Petechiae:-



Bruising:-



Hair loss



Rash:-

Past Hx:-

1)past medical:-



Hx of any chronic disease:-



time of Dx:-



Number of attack:-



Medication used to treat it:-



Medical follow up for that disease :



Hx of infectious dis:-



Hx of previous hospitalization:-



Hx of allergy (asthma,eczema,hay fever):-

Peri natal Hx :-

--prenatal:-



Age of mother:-



Anemia:-



Any Dis in pregnancy:-



G.D.M:-



Hypertension:-



Morning sickness:-



Smoking:-



Ante natal care:-



Medication received in pregnancy:-



Vaccination during pregnancy:-



Edema"in 3

Tms"



Hx of infertility:-



X-rays exposure:-

--natal :-



Mode of delivery:-if it was cesearean section mention the indication.



Term or preterm"G.A":-



At home or hospital:-



Complications of labor:-

--Post natal:-



Wt of baby soon after birth:-



Jaundice:-



RDS:-



Anomalies:-



Cyanosis:-



Convulsion':-



Bleeding

--Drug Hx:-

Past-surgical:-any operation the pt had undergone(circumcision is included)

Vaccination Hx:-

 --1st visit:-1

week or 72 hrs:-BCG:bacillus calmette Guerin:-live attenuated vaccine

--S.C//Scar formed after 3wks

(look for the scar)

--HBV:-I.M:DNA recombinant" contains one of the viral envelope proteins, hepatitis B
surface antigen (HBsAg)"in thigh

--OPV:-2drops in the mouth:-whole inactivated m.o

  2months1-DPT:-diptheria &tetanus :toxoid:non toxic toxin:modified
  Pertussis :-part of the organism
  Given i.m

2-HBV
3-Hib :polysaccharide capsule ..i.M

4-Rota:-orally:-live attenuated m.o
5-Opv:-whole organism is inactivated

 4months



DPT

Hib
Rota
Opv

Pcv"

Pneumococcal conjugate vaccine

":-polysaccharide capsule conjucated to proteins

carriers.

 6monthsame as 2

month

  9month measles:live attenuated m.o
  15monthsMMR:-live attenuated m.o
  18monthopv,Hib,DPT



4-6yrsDPT,OPV,MMR

Feeding Hx:-



Type of feeding:-



Sign of satisfaction:-



Frequency &amount (duration in breast milk):-



How many bottle she has?it should be equivocal to the number of feeding.



Mode of sterilization of bottles feeding:-



Introduction of added food ?

Developmental Hx:-



6-8weeks



raises head to 45//smile responsively//turn the head



3months



vocalises alone



6-8months



1.head control

2.sitting with support of his hands on the ground & his back is arched.

3.rolls over

4.parachute reflex
5.palmar grasp



7-8months



crawling



9months



walks around furniture//waves bye bye//dada-mama//pincer grasp



12months



walks unsteadily//broad gait//hands apart



14months



scribbles

family Hx :-



Parent's age :-
mother :-
father:-



condition of health:-



consanguinity between parents:-



The number of the child pt(infant)in the family



Number of sibling:-



any chronic dis in the family:-



similar condition in other member of the family :-