PEDIATRIC HISTORY FORM

RIC/ROD ADMITTING NOTES

General Data:
This is a case of a Gaviola, Raizen, 5 months old female, catholic, born on 8/17/17, who came in due to dyspnea

Chief Complaint: Dyspnea

History of Present Illness:

9 days PTA, good activity good appetite
no fever, tachypneic
increased respiratory effort (alar flaring)
(-) cyanosis (-) fever

8 days PTA, Still with above signs and symptoms

consulted private pedia –
Ambroxol drops, 3 ml TID
Amoxicillin drops 3 ml,TID;
Salbutamol neb 3x a day -- compliant,

2 days PTA Dyspnea increased in seveity

(+) cyanosis (-) fever --- > relieved

Condition progressed until 1 day PTA, (+)tachypneic, nasal congestion

(-) fever, good appetite,
patient consulted to another private MD, advised admission due to
dyspnea

PAST MEDICAL HISTORY

Seizure Disorder - Animal Bite - Previous hospitalization:
Allergies - Bronchial asthma -
Trauma/Fall - PPTB -

FAMILY HISTORY
Bronchial asthma - Hypertension - Heart Disease -
Tuberculosis - Diabetes Mellitus - Renal Disease -
Seizure Disorder - Malignancy - Others -

PERSONAL, SOCIAL AND ENVIRONMENTAL HISTORY

AGE Occupation Smoking/Alcoholic Cooking
Patient Water supply
Mother Garbage Collection
Father Piggery
Siblings Factory/Poultry

IMMUNIZATION HISTORY
No. of doses No. of doses
BCG - Pneumococcal -
Hepatitis B - Hepatits A -
DPT/HepaB/Hib - Measles -
OPV - MMR -
Rotavirus - Influenza -

*Completed at ______________________
Feeding history:
Breast feeding Motor (Gross and Fine) H
Formula milk Adaptive E
Language A
Social and emotional Responsive when talked to, coos D
Complimentary feeding Cognitive S
Solid food S
Feeding problem

Birth and Maternal history:

Postnatal History:
The baby cries loudly at birth with no medications or congenital defects noted.
Unusual signs/symptoms (cyanosis, apnea, jaundice, convulsions or pallor): ___________________________________
Spontaneous cry? ________
Oxygenation or resuscitation? ___________________
Medications? ___________________________________
Congenital defects: _____________________________________
 REVIEW OF SYSTEMS
Weight (-) weight loss (-) weight gain
Skin (-) weight gain, (-) adenopathy (-) lumps (-) bruising (-)bleeding (-)hypo/hyperpigmentation
HEENT (-) Headaches (-)concussions (-)strabismus (-)conjunctivitis (-)visual problems (-)hearing problems (-)ear
infections (-)sore throat (-)epistaxis
Respiratory (-) Dyspnea (-)stridor (-) orthopnea (-)cyanosis
Cardiac (-) Cyanosis (-) exercise intolerance (-)chest pain (-) palpitations
Gastrointestinal (-) changes in stool over characteristic______________________________________________
(-) diarrhea (-) constipation (-) vomiting (-) hematemesis
(-) abdominal pain
Genitourinary (-) frequency (-)dysuria (-)oliguria/polyuria (-) hematuria
Musculoskeletal (-)joints or swelling (-) myalgia (-) injuries (-) gait changes

PHYSICAL EXAMINATION

General Survey:

Vital signs: T: HR: RR: BP

Anthropometrics (Include z scores)

Weight :
Height and Length :
HC :

Skin and lymph

HEENT

Chest and Lungs

Cardiovascular

Gastrointestinal

Genitourinary

Extremities

Neuro Exam