PEDIATRICS HISTORY TAKING (MY PROTOCOL)

I. PATIENTS PROFILE II. PRESENTING COMPLAINTS III. HISTORY OF PRESENT ILLNESS IV. BIRTH HISTORY V. FEEDING HISTORY VI. IMMUNIZATION VII. DEVELOPMENTAL HISTORY VIII. PAST HISTORY IX. PERSONAL HISTORY X. DRUG HISTORY XI. FAMILY HISTORY XII. SOCIO-ECONOMIC HISTORY

I. PATIENTS PROFILE
1) 2) () *) /) Name Age Da!e "# $%&!') Se) A++&e,, "# -a&e.!, Da!e "# a+m%,,%".

II. PRESENTING COMPLAINTS

(Use parents own words + chronological order)

III. HISTORY OF PRESENT ILLNESS

1) E.01%&e a, !" 2'e. -a!%e.! 2a, 3a,! e.!%&e34 2e335 2) P&e,e.!%.g 6"m-3a%.!, a) Time (onset , duration , frequency , course) b) Place (site) c) Quality (character e.g. of pain , composition of vomitus) d) Quantity (severity of pain , amount of vomitus) e) Provocative / alleviative factors / variations (diurnal or seasonal) f) Associated symptoms g) Treatment if any () S4,!em%6 %.01%&4 a) General (weight loss , appetite) b) CVS (shortness of breath on exertion , shortness of breath and sweaty on feeding, cyanotic spells, squatting, fainting or syncope, cyanosis, edema, chest pain palpitations)

c)

Respiratory system (sore throat, earache, cough, whee!e, frequent chest infections, history of aspiration, hemoptysis) d) Gastrointestinal system (abdominal pain, vomiting, "aundice, diarrhea constipation, blood in stools) e) C S (fits, syncope di!!iness, headache, visual problems, numbness unpleasant sensations, wea#ness frequent falls, incontinence) f) Genitourinary system (stream, dysuria, frequency, nocturia enuresis, incontinence, hematuria) g) R!eumatological system (limp, "oint swelling, hair loss, s#in rash, dry mouth mouth ulcers, dry or sore eyes, cold extremities)

"V# $"RT% %"ST&R'

($mportant in neonatal, genetic or developmental case) ANTENATAL HISTORY H7O PREGNANCY) %) % ( status (&ealth and nutritional status of mom during pregnancy) ') "llness during pregnancy (&(), *+, pre,eclampsia, antepartum haemorrhage) -) "nfections during pregnancy (rubella, U($s, syphilis, (..#) /) )rugs (iron, multivitamin, other drugs with dose, duration and at which time of gestation) 0) *+ray (h o irradiation in %st trimester) 1) TT (maternal vaccination against tetanus) 2) Past o,stetric (problems with previous pregnancies, stillbirths, miscarriages, birth weight of previous children, prematurity, blood transfusions) NATAL HISTORY H7O DELIVERY) %) ') -) /) 0) 1) 2) Place of delivery (hospital home) Conducted ,y (dai trained health visitor doctor) Sterili.ation tec!ni/ue for instruments Gestation time (length) Rupture time (time of rupture of membranes) 0a,our time (duration) Presentation and type of delivery (34*, forceps, vacuum extraction or 5,section) 1) Sedation/analgesics during la,our 6) Complications (abnormal bleeding) POSTNATAL HISTORY %) 2ST cry (immediately cyanosed apneic) ') $asic pro,lems (need for resuscitation, problem with respiration, suc#ing swallowing) -) $irt! 3eig!t 4) $irt! in5ury 6) Convulsions7 cyanosis7 5aundice7 fever7 ras! 1) Procedures (exchange transfusion, umbilical artery catheteri!ation, drugs)

V# 899)" G %"ST&R'
3ignificant in child 7 ' years , anemic or malnourished) 1) O.,e! "# #ee+%.g after how many hours) 2) T4-e "# #ee+ $&ea,!-#e+ duration) $"!!3e-#e+ at what age, composition of formula, amount, frequency, dilution) () S1--3eme.!, vitamin, iron) *) 8ea.%.g when, what, amount, frequency) /) C1&&e.! +%e!76'a.ge %. +%e! +1&%.g %33.e,,

V"# "::; "<AT"&

chec# vaccination card 8 ) 1) T4-e, "# Va66%.a!%"., g%9e. 2) Age a! 2'%6' ,!a&!e+ a.+ :4 2'"m () D",e, ; a+9e&,e e##e6!,

V""# )9V90&P:9 TA0 %"ST&R'

1) A6'%e9%.g age "# 9a&%"1, m%3e,!".e, Sm%3%.g A:%3%!4 !" '"3+ .e6< S%! C&a23 S!a.+ 8a3< Ta3< C".!&"3 "# :3a++e& a.+ :"2e3 2) C"m-a&e+ 2%!' ."&ma3 #"& !'%, age

VIII. PAST HISTORY

1) S%g.%#%6a.! %33.e,, %. !'e -a,! esp. diarrhea, respiratory infections, fevers, fits, "aundice ) 2) H%,!"&4 "# ,%m%3a& 6"m-3a%.!, %. !'e -a,!

IX. PERSONAL HISTORY

1) 2) () *) Pa&!%613a& 'a:%!, "# 6'%3+ De!a%3, "# 63a,,= ,6'""3 a.+ %.!e&e,! %. ,!1+%e, A.4 m%,,e+ ,6'""3 a!!e.+a.6e $e'a9%"& "# !'e 6'%3+ a! ,6'""3 a.+ &e3a!%".,'%- 2%!' "!'e& 6'%3+&e.

X. DRUG HISTORY
1) A.4 me+%6a!%"., 1,e+ frequency, dose, adverse effects) 2) A33e&g4 !" a.4 +&1g () H7" M"m +&1g 1,age >> in neonate or breast fed baby)

XI. FAMILY HISTORY

$mportant in chromosomal, hereditary, infectious diseases ) 1) 2) () *) Age "# m"!'e& a.+ #a!'e&5 H"2 3".g ma&&%e+5 C".,a.g1%.%!4 >>> Pa&e.!, 'ea3!' present and past) S%:3%.g, N1m:e& Age a.+ ,e) I33.e,, A.4 +ea!' cause if #nown or symptoms of illness before death) S!%33:%&!',= m%,6a&&%age,

/) G&a.+ -a&e.!, 'ea3!' esp. if living with family) ?) Hea3!' "# 1.63e,= a1.!, a.+ !'e%& 6'%3+&e. if inherited disorder suspected) 2) *9 +:;< : =:+$>? (@<< 888

XII. SOCIO-ECONOMIC HISTORY

1) 2) () *) /) ?) Pa&e.!, e+16a!%". a.+ "661-a!%". Fam%34 %.6"me H"1,e made of, persons living, si!e) C3ea.3%.e,, a.+ ge.e&a3 '4g%e.%6 6".+%!%"., S"1&6e "# +&%.<%.g 2a!e& A.4 -e!, a! '"me