History

Personal History :
Name :
Age :
Sex :
Nationality :
Date & Place of birth :
School :
Father's Name & Occupation :
Mother's Name & Occupation :
Origionally from :
Lives in :

Informant & reliability :

Chief Complaint:
ER or OPD Admission
How many days
Shief Complaint :
Duration of CC :

History of Present Illness:

Hx of Chronic Diseases
When Dx
Where ?
what complaint
investigation ?
MGM ?
ER Visit / Month ?
Admissions / year ?
medications ?
complication of ttt ?
complication of Disease ?
Analyse symptoms of this admission

Interval History:
Well Child :
illnesses , TTT
Rx to Immunization
Chronic ill child :
condition since last visit
current medication
frequency of Medication

Family response to illness

Past History:
Prenatal:
antenatal care ?
US ? How frequent ?
Any abnormality was detected ?
Hx of DM
Hx of HTN
Hs of exposure to Radiation
Hx of Bleeding

Natal:
Delivery ?
normal spontaneous vaginal delivery.
Caesarean Section ? Why ?

Neonatal:
Hx of Complication during delivery
Hx of birth asphyxia
Hx of jaundice

Past medical Hx
Hospitalization
Past surgical Hx
Developmental History:

Smile 3 M
Da Da Ma Ma 7 M
Creeps on hand & Knnes 10 M
Walk 12 M
Sphincter control by Day time 18 M

Vaccination:
Took all required Vaccine up to date ?
How # viaccine Missed ?
Special Vaccine ?

Personal History & Habits :

Relation to other Children
School Progress
Eating : appetite , food dislike , how fed
Sleeping : hours , Disturbance , snoring
Exercise & Play
Behavior : bedwetting , thumb sucking , nail biting ,
tember tantrum

Nutritional History:
Breast or formula
Time of Weaning ? Why ?
Solid food
appetite
Food allergy

Family History:
Father : Age & condition of Health
Mother : Age & condition of Health
Consanguinity
Sibling : # , conditions
Maternal Pregnancy : stillbirths , miscarriage , abortions
family illnesses
Marital relationship

Social History:
where they are living ?
they own the house or rented
how many rooms ?
Socioeconomic state
Father's education , smoking or not
School Hx ?

Systemic Review:
CNS :
NERVOUSNESS
CONVULSIONS
ATAXIA
WEAKNESS
UNUSUAL HEADACHE
DIZZINESS
HEAD TRAUMA

EYES :
BLURRING OF VISION
DIPLOPIA
PHOTOPHOBIA
EYE PAIN OR ITCHING OR TRAUMA
USE OF EYE DROPS OR FAMILIAL EYE DISEASES.

EAR :
HEARING LOSS
EAR PAIN OR ITCHING
EAR DISCHARGE

TINNITUS

OR VERTIGO.

NOSE :
NASAL OBSTRUCTION OR EPISTAXIS
POST NASAL DISCHARGE
CHANGE OF SMELL SENSATION
SINUS PAIN
NASAL DRIP
SNORING

MOUTH

AND

THROAT:

BLEEDING TENDENCY
SWELLING OF GUM
ULCER OF TONGUE
MOUTH ULCER
DISTURBANCE OF TASTE
FREQUENT SORE THROAT

TEETH :
AGE OF ERUPTION
# OF TEETH AT ONE YEAR OF AGE
TEETH FALL

CARDIOVASCULAR SYSTEM:
CHEST PAIN
DYSPNOEA
ORTHOPNEA

PND
PALPITATIONS
COUGH OR SPUTUM
ANKLE SWELLING
INTERMITTENT CLAUDICATION

RESPIRATORY SYSTEM:
COUGH
SPUTUM OR
HEMOPTYSIS
DYSPNOEA
CHEST PAIN
NIGHT SWEAT
HOARSENESS

GASTROINTESTINAL SYSTEM:
ABDOMINAL PAIN
ABDOMINAL DISTENTION
VOMITING
DIARRHEA
CONSTIPATION

JAUNDICE
PRURITIS

RETICULO-ENDOTHELIAL SYSTEM:
LYMPH NODE ENLARGEMENT
TENDERNESS OR SUPPURATION
UPPER ABDOMINAL MASS.

GENITO-URINARY SYSTEM:
ENURESIS
DYSURIA
FREQUENCY
POLYUREA
HEMATURIA
VAGINAL DISCHARGE
ABNORMALITIES IN PENIS OR TESTIS

ENDOCRINE:
DISTURBANCE OF GROWTH
EXCESSIVE FLUID INTAKE
POLYPHAGIA
GOITER
THYROID DISEASE

MUSCULO-SKELETAL SYSTEM:
JOINT STIFFNESS
RESTRICTION OF MOTION
JOINT SWELLING
POSTURAL DEFORMITIES
BONY DEFORMITY
MUSCULAR PAIN
MUSCULAR WEAKNESS

HEMATOLOGICAL SYSTEM:
Bruises
tendency to bleed easily
history of thrombosis

SKIN :
color
texture
bruises
rash
eruption
itching
pigmentation
abnormal hair or nail growth

PHYSICAL EXAMINATION
GENERAL APPEARANCE:
LOOK ( ILL OR WELL )
DYSMORPHIC FEATURES
NUTRITIONAL STATE
COLOR

VITAL SIGNS :
PULSE RATE :
BLOOD PRESSURE:
RESPIRATORY RATE:
TEMPERATURE:

GROWTH

PARAMETERS:

WEIGHT: 20.5 KG, AT THE 25THPERCENTILE.

HEIGHT: 124 CM, AT THE 75TH PERCENTILE.
HEAD CIRCUMFERENCE: 58 CM

HEADS

AND

NECK :

EYES :
CONJUNCTIVA
SCLERA
STRABISMUS

FACE :
PIGMENT
TELANGIECTASIAS
SALIVARY GLAND ENLARGEMENT.

EARS :
AURICLE
DISCHARGES.

NOSE :

OBSTRUCTION
NASAL POLYPS
SINUS TENDERNESS
CLEFT PALATE
NOSTRIL ATRESIA

MOUTH AND ORAL CAVITY :

ORAL HYGIENE
BUCCAL MUCOSA
ULCERS
GUM
TONGUE

NECK :
JVP
CAROTID
TRACHEA
LYMPH NODES
THYROID

HAND &

ARM:

NAIL :
CLUBBING
CYANOSIS
PALLOR
DEFORMITIES
PALM :
WARM, MOISTURE
PALMER CREASE
MUSCLE WASTING
DORSUM :
MUSCLE WASTING
PURPURA
TELANGIECTASIAS.

LOWER LIMBS:
POSTURE
PIGMENTATIONS
DILATED VEINS
NAIL CHANGE
DEFORMITIES
JOINT SWELLING
ULCERS
PULSES

CHEST :
INSPECTION:
SYMMETRICITY
CHEST DEFORMITIES
TYPE OF BREATHING
CHEST WALL VEINS OR TELANGIECTASIAS APEX BEAT
VISIBLE ON MID-CLAVICULAR LINE AND NO OTHER
VISIBLE PULSATIONS.

PALPATION :
TENDERNESS
SUBCUTANEOUS EMPHYSEMA
CHEST EXPANSION
TACTILE VOCAL FREMITUS

PERCUSSION:
AUSCULTATION:
AIR

ENTRY
INTENSITY
TYPE OF BREATHING
VESICULAR
BRONCHOVESICULAR
BRONCHIAL
ADDED SOUND
WHEEZE
CREPITATIONS
FRICTION RUB
VOCAL RESONANCE

HEART
INSPECTION :
CHEST DEFORMITIES
PRECORDIAL BULGE
VISIBLE PULSATION
NO SCARS

PALPATION :
APEX

BEAT
PARASTERNAL HEAVE
NO PALPABLE THRILL.

AUSCULTATION:
S
S2
ADDED SOUNDS
MURMUR
TIME
GRADE
CHARACTER
BEST HEARD
RADIATION
MANEUVER

ABDOMEN :
INSPECTION:
SYMMETRICITY
UMBILICUS
SCARS CATTERY MARKS OR STRIAE.
SKIN PIGMENTATION.
DILATED VEINS.
VISIBLE PULSATION.
VISIBLE PERISTALSIS.

PALPATION :
SUPERFICIAL

PALPATION:

TENDERNESS
SUPERFICIAL MASSES

DEEP PALPATION:
DEEP
DEEP

TENDERNESS
MASSES

ORGAN PALPATION:
LIVER
SPLEEN
KIDNEY
ASCITIS
PERCUSSION :
AUSCULTATION :
BOWEL SOUNDS
VASCULAR BRUIT
VENOUS HUM.
FRICTION RUB.

NEUROLOGICAL EXAMINATION:
GENERAL :
INTERACTION
ACTIVITY
POSTURE
SKIN CHANGES

MSE :
RESPONSE TO ENVIRONMENT
ACTIVITY

CRANIAL

NERVES:

OLFACTORY
OPTIC :
VISUAL ACUITY
VISUAL FEILED
PAPILLARY REFLEX
FUNDOSCOPY

3RD , 4TH , 6TH :

5TH :
SENSORY :
MOTOR
REFLEXES
FACIAL :
SENSORY ( ANT 2/3 OF TONGUE
MOTOR :
RAISE YR BROWS
CLOSE THE EYES
SHOW YR TEETH
BLOW

8TH :
HEARING
WEBER & RINNE
CALORIC TEST
NYSTAGMUS
9TH & 10TH : GAG REFLEX

11TH
12TH

UPPER

LIMB:

RIGH
T

TONE
POWER
REFLEX
SENSATIO
N

LEFT

NL
5/5
++

NL
5/5
++

NL

NL

GAIT

AND COORDINATION: THE PATIENT GAIT IS

NORMAL WITH NORMAL COORDINATION.

NEGATIVE SIGNS OF MENINGIAL

1\ -VE NECK STIFFNESS.
2\ -VE KERNIGS SIGN.
3\ -VE BRUDZINISKI SIGN.

IRRITATION

LOWER LIMB:
TONE
POWER

HIP
HIP

FLEXION

EXTENSION
HIP ADD.
HIP ABD.
KNEES FLEX.
KNEES EXT.
DORSIFLEXIO
N
PLANTER
FLEXION

RIGHT
NL
5/5

LEFT
NL
5/5

5/5

5/5

5/5
5/5
5/5
5/5

5/5
5/5
5/5
5/5

5/5

5/5

5/5

5/5

REFLEX

SENSATIO
N

KNEES
ANKLE
PLANTER
CLONUS

++
++
NL
-VE

++
++
NL
-VE

TOUCH

NL

NL

TEMP.
JOINT
POSITION
VIBRATION

NL

NL

NL

NL

NL

NL

DIFFERENTIAL DIAGNOSIS:
123-

INVESTIGATIONS
MANAGEMENT