Anda di halaman 1dari 12

PEDIATRIC HISTORY

History No. ___________ Preceptor: _____________________

Name of Patient _______________________ Date of Interview: _____________________

Informant _______________________ Date Submitted: ______________________

Reliability _______________________

Historian:

Group No. 12

GENERAL DATA

Name: _______________________ Age: _______________________

Gender: _______________________ Religion _______________________

Date of Birth ______________________ Place of Birth:___________________

Residence _______________________ Nationality _____________________

No. of admissions in that particular hospital ___ Date of Present Admission _________

CHIEF COMPLAINT: _______________________________

HISTORY OF PRESENT ILLNESS:

Onset ___________________________________________________________________

Previous treatments given ________________________________ Relieved? Y ( ) N( )

Description of symptoms ______________________________________________________

Character ______________________________

Location ______________________________

Intensity ______________________________

Timing ________________ Duration ______________ Frequency _____________

Associated S/S ______________________________

Aggravating Factors ______________________________

Relieving Factors ______________________________

**for neonates start at birth


End Statement: Reason for decision to seek consult today

____ hours/days/weeks Prior to consult, patient experienced ________________________.


Treatment given? _________________________ with no relief. Hence, was brought to FMC
for consult.

PAST MEDICAL HISTORY

A. BIRTH AND PRENATAL HISTORY


1. Neonates and Infants

Maternal History:
Age: __________
OB Score: G __ P __ (Full term __- Premature __- Abortions __- Living __)
Health during pregnancy: Poor ( ) Fair ( ) Excellent ( )
Bleeding ( ) Trauma ( ) Hypertension ( )
Gestational DM ( ) Fever ( ) Infections ( )
Radiation exposure ( ) Alcohol ( ) Smoking ( )
Rubella immunity ( ) Hepa B ( ) ROM ( )
Medications/Drugs taken _______________________________________

Labor and delivery


Gestational age at delivery __________ Spontaneuos ( ) Induced ( )
Duration of labor __________
Duration of ROM prior to delivery __________
Medications/Anesthesia __________________________________
Fetal presentation: Vertex ( ) Breech ( ) Others __________
Type of Delivery: Vaginal ( ) Forceps ( ) Cesarian ( )
Home ( ) Hospital ( )
Meconium-stained? Y( ) N( )
Birth weight: __________

2. All Children
Neonatal History Y N
APGAR SCORE (if known) __________
Breathing problems ( ) ( )
Remarks:____________________
Use of oxygen ( ) ( )
Remarks:____________________
Need for ICU ( ) ( )
Remarks: ____________________
Problems in nursery ( ) ( )
Meconium-stained ( ) Birth injuries ( ) jaundice ( )
Feeding difficulty ( ) Respi distress ( ) hyperbilirubinemia ( )
Other complications ______________________________
Length of stay in nursery __________

Estimated Gestational Age __________ Birth weight __________


B. PAST ILLNESSES

1. Childhood Illnesses Age Complications Treatment


Chickenpox ( ) _____________ ______________ _________________
Measles ( ) _____________ ______________ _________________
Mumps ( ) _____________ ______________ _________________
Polio ( ) _____________ ______________ _________________
TB ( )
Rheumatic fever ( ) _____________ ______________ _________________
Pneumonia ( ) _____________ ______________ _________________
Whooping cough ( ) _____________ ______________ _________________

2. Recent infection exposure


Date: _____________ Travel to other locations _____________ animal exposure ___________

3. Previous hospitalizations
Date Age Reason Length of stay Location
_________ _____ _________________ _____________ _____________
_________ _____ _________________ _____________ _____________
_________ _____ _________________ _____________ _____________

4. Previous Surgery/ Transfusions

Dates Age Indication Type of Operation Recovered?

________ ____ ___________________ _______________ Y( ) N( )

________ ____ ___________________ _______________ Y( ) N(

Complications/Allergic reaction: ______________________________

5. History of:

Trauma ( ) Ingestion ( ) Fractures ( ) Lacerations ( )


Age: _______________
Circumstances surrounding event: _______________
Treatment: _______________
Complications: _______________

6. Allergies

Medications: ______________________________________________

Food: ______________________________________________

Insects: ______________________________________________

Environmental factors: _________________________________________


7. Medications (at present):

Drug Indication Frequency Length of Use Reason for d/c

________ _______________ _______________ ___________ ________________

________ _______________ _______________ ___________ ________________

________ _______________ _______________ ___________ ________________

C. IMMUNIZATIONS

DPT ( ) BCG ( ) MMR ( ) Measles (rubeola) ( ) HEPA B ( )

HEPA A ( ) HIg ( ) PCV ( ) Rotavirus ( ) Typhoid ( )

ATS ( ) FLU ( ) Varicella ( ) TETANUS TOXOID ( ) Meningococcal ( )

H.influenza ( ) Pneumonia ( ) HEPA B ( ) Rabies ( ) Others _______________

Booster dose? (and year) _______________________

Screening Tests

Tuberculin Test ( ) PPD ( ) Stool exam w/ OB ( ) Urinalysis ( )

CBC ( ) CXR ( ) NBS ( )

Others: ____________________________________

Results: ______________________________ Date last performed: __________________

Date of Last check-up: _________________ Last dental exam: _____________________

D. DEVELOPMENTAL HISTORY (age)

Gross Motor: __________________ Fine Motor: __________________

Language: __________________

Personal and Social

School Performance (pre-school and school children)

Poor Fair Excellent

1. Language Skills ( ) ( ) ( )
2. Reading Skills ( ) ( ) ( )
3. Writing Skills ( ) ( ) ( )
4. Sequential concepts
& math skills ( ) ( ) ( )
5. Problem solving,
Reasoning & Moral
Development ( ) ( ) ( )

Pubertal History (Adolescents)

1. Male
Age of onset ____________ Genital Enlargement ____________ Pubic hair _________
2. Female
Age of onset ____________ Breast Enlargement ____________ Pubic hair _________
Menarche ____________ Frequency of Menses ___________ Duration __________
LMP ____________ Dysmenorrhea: Y ( ) N( ) Medications taken _________
Flow: heavy ( ) moderate ( ) mild ( )

E. NUTRITION/DIET HISTORY
1. Infants
Breastfed ( ) Bottle-fed ( ) Frequency ____________ Amount _____ Problems: _________
Age of weaning ____________ Problems in weaning? ____________
Change in formula N( ) Y( ) Why? ________________________
Peculiar eating habits (e.g. pica) ________________________
Vitamins/Mineral supplements (with dose and frequency) ___________________________________

2. Older Children
Appetite: Poor ( ) Good ( ) Excellent ( )
Special diets: ____________________________________
Food Preferences: ____________________________________
Intake of: milk ( ) junk food ( ) Others ____________
Concerns about weight: ________________________
Vitamin/Mineral supplements: ____________________________________

FAMILY HISTORY

Age Health History Cause of Death (if deceased)

Grandmother ____ ____________ _______________________

Grandfatherfather ____ ____________ _______________________

Mother ____ ____________ _______________________

Father ____ ____________ _______________________

Siblings:

_______________ ____ ____________ _______________________


Family History of: (paternal or maternal side)

HPN ( ) CAD ( ) Elevated Cholesterol ( ) Stroke ( )

Asthma ( ) Lung dse ( ) Headache ( ) Seizure d/o ( )

Vertigo ( ) Mental Retardation ( ) Mental Illness ( ) Subs Abuse ( )

Arthritis ( ) Cancer ( ) DM ( ) Thyroid d/o ( )

Renal dse ( ) Allergies ( ) Tuberculosis ( ) Depression ( )

Glaucoma ( ) Chromosomal abno ( ) miscarriage ( ) infant/childhood deaths ( )

Developmental delay ( ) Congenital anomalies ( ) Growth problems ( )

Others:_______________________________________

ENVIRONMENTAL AND SOCIAL HISTORY

A. INFANTS AND OLDER CHILDREN

Occupation Educational Attainment

Father : _________________ _________________

Mother: _________________ _________________

Composition of Family

Nuclear ( ) Extended ( )

Daycare:_______________________________________

Home condition: Owned ( ) Rented ( )

House made of: Light ( ) Wood ( ) Cement ( )

Congested area: Y ( ) N( )

Ventilation: Poor ( ) Fair ( ) Excellent ( )

Water Supply : _______________________________

Sewage disposal: Toilet _______________________

Garbage: _____________________

Safety measures employed: _______________________________

B. ADOLESCENTS (HEADSSS)
1. Home
Living arrangement: _________________
Recent changes in living arrangement? N ( ) Y ( ) _________________
Relationships in home _________________ Issues causing arguments _________________
Economic issues _________________ Stresses in home _________________
Forms of discipline _________________ Anything you like to change in family _________
2. Education
In-school ( ) out of school ( ) employed ( ) _________________
Favorite subject _________________ Average last grading/semester _________________
Problems with classmates/teachers? N ( ) Y( ) _________________
Ever been truant/suspended/expelled? N ( ) Y( )
Future education/employment goals: __________________________________
3. Activities
In spare time: _________________ Hobbies & interests: _________________
Time spent watching TV/playing computer games/using internet: _________________
With whom do you spend time with? _________________
Any close friends? _________________ Are they attending school? Y ( ) N ( )
4. Drug use
Tobacco ( ) alcohol ( ) drugs ( )
If yes: Frequency _________________ amount _________________
How & when started: __________________________________
Effects on daily activities: _________________
5. Sexual activity
Sexual orientation: _________________ Dating? Y ( ) N ( )
Active sexual activity: Y ( ) N( ) Use of contraception: Y ( ) N( )
History of sexual of physical abuse: Y ( ) N( )
6. Suicide/Depression
Feelings of sadness ( ) unmotivation ( ) Hopelessness ( )
Loneliness ( ) Reason? __________________________________
Has he thought of hurting himself? Y ( ) N ( ) Has suicide plan? Y ( ) N( )
7. Safety
Seatbelts ( ) helmets ( ) member of fraternity/gang ( )
Carry weapon for protection ( ) presence of firearms at home ( )
Others: ___________________

REVIEW OF SYSTEMS

General

Usual weight _____ Recent weigh change _____ Fever ( ) Chills ( )

Weakness ( ) fatigue ( )

Skin

Rashes ( ) Hives ( ) Moles ( ) Dryness ( )

Color change ( ) change in hairline ( ) itching ( )

HEENT

Decreased hearing ( ) Ringing in ears ( ) Frequent ear infections ( )


Dizzy spells ( ) Failing vision ( ) Double vision ( )
Blurred vision ( ) Eye pain ( ) Repeated eye infections ( )
Recurrent nose bleeds ( ) Dental disease ( ) Sinus trouble ( )
Frequent sore throats ( ) Neck swelling ( ) Hay fever ( )
Neck

Swollen glands ( ) Goiter ( ) Pain ( )

Stiffness ( )

Breasts

Lumps ( ) Pain or discomfort ( ) Nipple discharge ( )

Respiratory

Cough ( ) Sputum ( ) color: ________ quantity: ____________

Hemoptysis ( ) dyspnea ( )

Wheezing ( ) SOB ( ) Hoarseness ( )

Cardiovascular

RH fever ( ) hear murmurs ( ) Chest pain/discomfort ( )

palpitations ( ) dyspnea ( ) Edema ( )

irregular heartbeat ( ) Fainting spells ( ) Pain in legs when walking ( )

Gastrointestinal

Difficulty swallowing ( ) Indigestion ( ) Heartburn ( ) Nausea & Vomiting ( )

Loss of appetite ( ) Change in bowel habits ( ) pain with defecation ( )

Melena ( ) hematochezia ( ) jaundice ( )

Haemorrhoids ( ) constipation/diarrhea ( ) abdominal pain ( )

Food intolerance ( ) excessive belching/passing gas ( ) liver/gallbladder trouble ( )

Peripheral Vascular

Leg cramps ( ) Swelling in lower extremities ( )

color change in fingertips/toes during cold weather ( ) Swelling with redness or tenderness ( )

Urinary

Frequency of urination ( ) Polyuria/Nocturia/Urgency ( ) UTI ( )

Burning/pain during urination ( ) hematuria ( ) flank pain ( )


Kidney stones ( ) suprapubic pain ( ) incontinence ( )
Musculoskeletal

Muscle/joint pain ( ) stiffness ( ) arthritis ( ) gout ( )

Backache/low back pain ( ) swelling /redness/pain/tenderness/weakness ( )

Limitation of movement ( ) neck/nape pain ( )

Timing of symptoms: ______________________________________

Duration: _________________ Aggravating factors: __________________________________

Relieving factors: ___________________________ Treatment: __________________________

History of trauma: Y ( ) N ( ) describe: ___________________________________________

Systemic features (fever, chills, rash. Anorexia, wt loss. Weakness)? Y( ) N( )

Psychiatric (if relevant)

Nervousness ( ) Tension ( ) Mood changes ( )

Depression ( ) Memory change ( ) Suicide attempts ( )

Neurologic

Changes in mood ( ) attention/speech changes ( ) change in orientation ( )

Memory changes ( ) headache ( ) dizziness ( ) vertigo ( )

Fainting ( ) seizures ( ) weakness ( )

Paralysis ( ) numbness or loss of sensation ( )

Tingling/ pins and needle ( ) tremors/involuntary movement ( )

Difficulty falling asleep ( ) Difficulty staying awake ( )

Increased irritability ( )

Hematologic

Anemia ( ) Easy bruising/bleeding ( )

Past transfusions ( ) transfusion reactions ( ) _________________________________________

Endocrine

Thyroid trouble ( ) heat/cold intolerance ( ) excessive sweating ( )

Excessive thirst/hunger ( ) polyuria ( ) change in glove/shoe size ( )

Chronic fatigue ( ) recent weight loss ( ) tremors (shaking hands) ( )

Convulsions ( )
Reproductive (adolescents)

Secondary sexual characteristics ( ) menstrual problems ( )

Pregnancies ( ) sexual activity ( )

PHYSICAL EXAMINATION

I. GENERAL SURVEY
A. Weight ____________ height _____________
B. Nutritional Status Poor ( ) Fair ( ) Excellent ( )
C. Respiratory distress + ( ) -( ) cyanosis ( )
D. Level of Consciousness alert ( ) drowsy ( ) lethargic ( )
E. Type of cry or voice
F. State of hydration (ask about urine output) _____
Skin turgor: poor ( ) good ( )
Capillary refill poor ( ) good ( )
G. Posture and Gait ___________________________

II. VITAL SIGNS

Temp ___________ BP ___________ CR ___________ RR ___________

HC _________ AC __________ CC __________


III. SKIN
A. Birthmarks _____________________
B. Color: Pale ( ) cyanotic ( ) flushed ( ) jaundice ( )
C. Lesions: Rashes ( ) petechiae ( ) desquamation ( ) pigmentation ( )
D. Texture _____________________
E. Lymph node enlarment ( ) location __________ mobility __________
Consistency __________
F. Scars or injuries __________________________________________________
IV. HEENT
Head
A. Size and shape ____________________
B. Fontannel: close ( ) open ( ) bulging ( ) sunken ( )
Tension: ______________________________
C. Sutures: overriding ( ) normal ( )
D. Scalp and hair ________________________

Eyes
Strabismus ( ) slanting of palpebral fissures ( ) ptosis ( )
Visual tracking ( ) conjunctiva: pale ( ) normal ( )
Icteric sclera ( ) PERLA ( ) red reflex ( )
Ears
Position __________ deformities ( ) discharges ( ) __________
Tympanic membrane __________
Nose
Patent ( ) nasal flaring ( ) discharge ( ) nasal septum: midline ( ) deviated ( )
Polyps ( ) Nasal mucosal color __________ sinus tenderness ( )
Mouth and Throat

Lip color: pale ( ) red ( ) cyanotic ( )

Fissures ( )

Bucal mucosa: dry ( ) moist ( ) vesicles ( ) color: __________

Number of teeth: __________ Condition: poor ( ) fair ( ) excellent ( )

Dental carries ( ) cleft palate ( )

Tonsils: exudates ( ) color __________

Posterior phalangeal wall: lymph hyperplasia ( ) bulging ( ) color __________

Gag reflex: present ( ) absent ( )

V. NECK
Tracheal position: midline ( ) deviated ( ) __________
Cysts ( ) Nodes ( )
Nuchal rigidity ( )

VI. LUNGS AND THORAX


A. Inspection
1. Pattern of breathing: abdominal ( ) thoracic ( ) use of accessory muscles ( )
Periodic ( ) apneic ( )
Retractions ( )
2. Chest wall configuration ____________________
B. Auscultation
1. Breath sounds: __________
Rales ( ) crackles ( ) wheeze ( ) ronchi ( )
Upper airway noise ( ) stridor ( )
VII. CVS
A. Auscultation
1. Rhythym: irregular ( ) regular ( )
2. Murmurs ( )
3. Quality of heart sounds ____________________
B. Palpation of pulses

Bounding ( ) easily obliterated ( ) faint ( )

VIII. Abdomen
A. Inspection
1. Shape protruberant ( ) scaphoid ( )
2. Umbilicus: moist ( ) dry ( ) foul-smelling ( ) discharge ( )
3. Hernias ( )
4. Muscular integrity: poor ( ) good ( )
B. Auscultation
1. Bowel sounds: active ( ) hypoactive ( )
C. Percussion: tympanic ( ) dull ( )
D. Palpation: rebound tenderness ( ) hard-board like ( ) masses ( )
IX. GUT
Male

Circumcised ( ) descended testes ( ) hydrocele ( ) inguinal hernia ( )

Urethreal meatus: normal ( ) epispadia ( ) hypospadia ( )

Female

Discharge ( )

Rectal (as indicated)

Patent ( ) haemorrhoids ( ) fistula ( ) fissures ( )

X. MUSCULOSKELETAL
A. Back
Sacral dimple ( ) kyphosis ( ) lordosis ( ) scoliosis ( )
B. Joints
Limitation in movement ( ) swelling ( ) tenderness ( )
C. Extremities
Deformity ( ) symmetrical ( ) edema ( ) clubbing ( )
D. Hips (use ortolani’s or barlow’s maneuver)
Dislocation ( ) normal ( )
E. Gait
In toeing ( ) out toeing ( ) bow-legged ( ) knock knees ( ) limping ( )
XI. NEUOLOGIC
A. Cranial Nerves
B. Motor:
Paresis ( ) paralysis ( ) spastic ( ) rigid ( ) flaccid ( )
Clonus ( ) carpopedal spasm ( ) tics ( ) tremors ( )
Romberg’s sign ( )
C. Reflexes intact hyperreactive hyporeactive
DTR (biceps, triceps, radial, knee, ankle) ( ) ( ) ( )
Cremasteric ( ) ( ) ( )
Primitive (Moro, rooting, sucking ( ) ( ) ( )
Fencing, babinsky, etc)
D. Sensory ( ) ( ) ( )
E. Cerebellar signs
Incoordination ( ) ataxia ( ) intention tremor ( ) past point ( )
Dysdiachokinesia ( ) nystagmus ( )

Anda mungkin juga menyukai