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    HX Taking of Peadiatrics

    Uploaded by

    Cahaya Al-Hazeenillah
    This document contains a medical history and physical examination for a pediatric patient. It includes sections on the patient's identifying information, chief complaint, history of present illness, review of symptoms involving multiple body systems, past medical history, medications, allergies, pertinent pediatric history including prenatal, birth, newborn periods, immunizations and developmental milestones. It also includes the patient's family, socioeconomic and physical examination details. The physical exam findings are recorded from head to toe.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    HX Taking of Peadiatrics

    Uploaded by

    Cahaya Al-Hazeenillah
    122 views5 pages
    This document contains a medical history and physical examination for a pediatric patient. It includes sections on the patient's identifying information, chief complaint, history of present illness, review of symptoms involving multiple body systems, past medical history, medications, allergies, pertinent pediatric history including prenatal, birth, newborn periods, immunizations and developmental milestones. It also includes the patient's family, socioeconomic and physical examination details. The physical exam findings are recorded from head to toe.

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    Hx Taking of Peadiatrics

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    This document contains a medical history and physical examination for a pediatric patient. It includes sections on the patient's identifying information, chief complaint, history of present illness, review of symptoms involving multiple body systems, past medical history, medications, allergies, pertinent pediatric history including prenatal, birth, newborn periods, immunizations and developmental milestones. It also includes the patient's family, socioeconomic and physical examination details. The physical exam findings are recorded from head to toe.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    122 views5 pages

    HX Taking of Peadiatrics

    Uploaded by

    Cahaya Al-Hazeenillah
    This document contains a medical history and physical examination for a pediatric patient. It includes sections on the patient's identifying information, chief complaint, history of present illness, review of symptoms involving multiple body systems, past medical history, medications, allergies, pertinent pediatric history including prenatal, birth, newborn periods, immunizations and developmental milestones. It also includes the patient's family, socioeconomic and physical examination details. The physical exam findings are recorded from head to toe.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 5

    Name of the child:

    name:
    Date of birth:
    Gender: Boy / Girl
    Hospital ID:
    of clerking:
    Date of admission:
    discharge:
    Address:
    Schooling ? Age:

    Nick
    Age:
    Race:

    Date
    Date of

    2) Chief complain :
    History of presenting Illness:

    3) Reviews of symptoms
    CVS
    Heart Murmur
    CHD
    Cyanosis of lips/
    tongue/nails/ skins/
    exteremities
    sweating
    palpitation,
    exercise tolerance,
    suck-pause-suck
    cycle / feeding less /
    takes longer to feed,
    breathlessness during
    feed or play
    Cough / wheeze/ stridor
    chest recessions
    ENT
    Ear discharge
    Snoring
    Keeps mouth open to
    breath
    Nasal / ear discharge,
    Pulling of ears / ear
    ache
    Endocrine system
    Neck swelling
    Excessive thirst /
    appetite
    urine
    Excessive sweating.
    Others:

    GIT
    / Appetite
    Vomitting
    loose stools /
    constipation
    -How many stools a
    day?
    -colour ?
    -foul smell ?
    abdominal pain
    jaundice
    abdominal distension
    postprandial hurry
    Perianal redness
    Abdominal pain
    weight loss / gain
    -How much?
    Failure to thrive
    Genitourinary system
    Passing urine
    - how many times?
    - Quantity same
    /different?
    - colour?
    -smell?
    -Appearance of urine ?
    clear / cloudy
    Painful urination / cries
    while passing urine
    Bedwetting / toilet
    trained
    Hematological
    system
    Pallor

    Neurological system
    Headache
    Photophobia
    seizures
    Abnormal movements
    Unsteadiness,
    Tremors
    Drowsiness
    loss of consciousness /
    syncope
    limp (floppy)
    Visual problems
    Stiff
    Diplopia
    Squint
    Movement of lips to
    one side while crying
    hearing
    Nasal regurgitation,
    Torticollis
    MSSK
    Pain / swelling of
    joints
    # spine or bones
    Unable to moving a
    limb
    Gait disturbance
    Crying on moving
    the limbs / on
    handling
    Skin
    Rashes
    Swelling/s

    Known to have
    bronchial asthma
    -Asthma
    since the age of
    ________
    Episodes once in
    _____ weeks
    Medications:
    _________________
    Last episode of
    asthma on: _____
    Home/ Hospital
    treatment
    Current condition
    well
    Fever
    Wheezing
    Cough
    Runny nose
    Shortness of
    breath
    Getting better /
    worse than
    before
    History of
    Nocturnal cough
    Frequency
    _________
    Allergic
    conjunctivitis
    Allergic rhinitis
    Eczema
    Allergy to food
    Allergy to drugs
    Otitis media
    Urticaria

    Precipitating
    factors
    exercise
    URTI
    cold weather
    cold drinks
    smoke
    dust
    pollen
    food
    Other factors
    __________________
    ____
    Family History
    Asthma in
    relatives:
    Allergic
    conjunctivitis
    Allergic rhinitis
    Eczema
    Urticaria
    Allergy to food /
    drugs
    Others
    Schooling: Missing
    school d/t asthma ________ days / year
    Home and living
    environment
    Smoker in the
    house
    Burn rubbish near
    house
    Pets / neighbours
    pet

    Birds / chicken
    farm
    House near
    roadside /quarry/
    factories
    Construction
    nearby
    Renovating house
    Mosquito coil /
    electric mat
    Insecticide sprays
    Bakhur / incense
    fumes
    Generators
    Fan cleaning
    once in --days
    Air conditioner
    filter cleaning
    Carpets
    Furry toys
    Favourite pillow
    Garden
    Grass
    Flowering plants
    Type of mattress
    Changing bed
    sheet once in
    days
    Clean the house
    using mop/
    broom/ vacuum
    School
    environment:
    Near
    roadside
    /quarry/
    factories

    Fever
    0
    C
    (Low grade/ High grade
    fever)
    -onset?
    -Pattern? Intermittent /
    continuous / Relieved by
    antipyretic
    -Intensity?
    -Associated symptoms?
    Runny nose/ Cough / Sore
    trout / headache/ chills/
    Rigor/Fit
    others:
    -Duration?
    Ds/ wk
    Date:
    -Diurnal? Day / Night
    -Any Family members had
    fever recently?
    -Disturbed Sleep?
    - Endemic area of dengue?
    -chills/ rigor?
    -Fogging? If yes:
    When?
    -Any medication / ways to
    relieves fever?
    Cough
    - + sore throat : want to
    Eat/ not ?
    - Ass with:
    Facial congestion
    Hoarness
    Wheezing
    SOB
    mins
    b/c Reddish / Bluish
    Where?
    -productive/ unproductive
    cough
    If productive cough:
    -colour:
    -quantity:
    -frequency:
    -characteristic:
    -Any medication?
    -Severity: Active / Inactive
    (Disturb while playing/
    doing activities)

    Vomitting
    -onset
    -colour:
    - has foul smelling/ Not?
    -frequency:

    -4) Past Medical Hx


    If yes
    S
    O
    C
    R
    A
    T
    E
    S
    Past Surgical Hx
    -What?
    -When?
    -Why?
    -Any difficulty?
    5) Medication
    Current:
    Past:
    6) Allergy Hx
    Drugs:
    Food:
    Others:
    7) Hx specific to
    Peadiatrics
    Prenatal Hx
    -Parents age:
    -Accidental/ Planned
    pregnancy
    -Term/Preterm/Post term
    Weeks of
    gestation
    - Check up? when:
    - Takes medication:
    folic acid/Iron/ other:
    F
    - Immunisation?
    M
    tetanus toxoid /
    -Hx of fever with rash : Y/N

    Gestational / Type 1
    diabetes
    Preeclampsia
    -When?
    - Pregnancy induced HTN
    - swelling of legs & hands
    - swelling of legs
    -Ecclampsia (seizures)
    Bleeding per vaginum,
    Ingestion of alcohol
    Exposure to smoking
    (active / passive)
    Any Illness?
    Exposure to x-rays /
    chemicals, traditional
    medications.
    Birth Hx
    -POB:
    - normal/ spontaneous,
    - vaginal/ induced
    /caesarian section/
    Ventouse (vacuum)?
    - Breech?
    - Duration of labour?
    hrs
    -Colour of amniotic fluid?
    - Any staining with
    meconium?
    - first cry?
    -APGAR score?
    Scor 0
    1
    e
    color Blu -Pink
    e
    body
    pal -Blue
    e
    Hand/
    feet
    HR
    <100/
    min
    Resp -Weak
    effor
    cry
    t
    Irregul
    ar
    breathi
    ng
    M
    Lim Bendin
    tone p
    g of
    some
    limbs

    2
    -All
    pink

    >100/
    min
    -Good
    crying

    Active
    motio
    n
    Limbs
    well
    flexed

    Neonatal Hx (first 4
    weeks of life)
    Jaundice
    Seizures
    Phototherapy
    Exposure to sun light
    Ventilated
    Exchange transfusion
    given,
    Feeding history
    Breast feeding?
    -BF immdediately after
    Birth?
    -Duration:
    -Suck-pause cycle
    Winning
    -When?
    -Types of food?
    Like/ Dislike
    Diet
    -Meals /day?
    -Menu?
    Sp/same with other
    family
    If sp:
    Immnunisation Hx

    -complete/ Incomplete
    cycle?
    If not yet,
    When next appointment?:
    Where?
    With?
    -Follow schedule/ x ?
    -Any Hx of fever/ rashes/
    itchy after immnunisation?
    Developmental history
    * use dev. Chart
    11) Family Hx
    -predigree chart
    -Name, age,
    gender,occupation, illness

    Socioeconomic history
    -Education / occupation of
    parents?
    -who take care of the
    children while parents
    working?
    -How many people live in
    the house?
    -Nuclear / Extended family
    -Type of house
    - How many bed rooms &
    how shared?
    - Water source, Electricity?
    -Financial status?
    How much:
    14) Physical
    examination:
    -Any obvious distress /
    -Any pain? If yes, where:
    -Alert / active/ playful/
    cooperative/ fears strangers
    -level of hygiene
    -Any developmental
    milestone?
    Vital signs:
    -1-minute PR:
    rhythm
    Volume
    Sp character?
    -felt in all peripheral
    vessels
    -any radial-radial /radialfemoral delay
    -1-minute RR:
    -BP:
    mm/Hg
    Anthropometric
    measurements:
    Weight:
    kg
    height:
    cm
    Head circumference:
    cm
    Percentiles?
    Hydration status:
    -Skin turgor/ mucous
    membranes?
    -Eyes (moistness, tears,
    sunken or not)
    -Anterior fontanelle?
    Neck: thyroid swelling
    Lymph nodes: neck, axilla,

    Periphery to centre:
    Extremities:
    Hands & feet:
    -skin is warm / cold?
    - colour (pale, cyanosed, jaundiced )
    - clubbing
    rashes
    swelling
    features of infective endocarditis
    capillary refill time
    pedal oedema in a walking child
    sacral oedema in infants / bed-ridden children
    Head:
    Dysmorphic features,
    Bulges
    anterior / posterior
    fontenelle
    sutures
    craniotabes /
    transillumination
    subcutaneous nodules
    Eyes:
    pallor
    injection of
    conjunctiva
    jaundice,
    redness
    eyelid swelling
    Stye
    chalazion,
    discharge
    ENT and mouth
    nasal / ear discharge
    hypertrophied terbinates
    redness of throat,
    mucosa of mouth
    Tonsilitis
    uvula,
    Petichiae
    ulcers / bleeding inside the
    mouth or gum
    koplik spots in suspected
    measles
    cyanosis
    state of gum / teeth
    number of teeth?
    Any otoscopic findings?
    Skin
    Pubertal assessment in adolescents
    Primitive reflexes in neonates and infants
    Neurocutaneous markers

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