PEDIATRICS HISTORY TAKING(MY PROTOCOL)

I. PATIENT’S PROFILEII. PRESENTING COMPLAINTSIII. HISTORY OF PRESENT ILLNESS

IV. BIRTH HISTORYV. FEEDING HISTORYVI. IMMUNIZATIONVII. DEVELOPMENTAL HISTORY

VIII. PAST HISTORYIX. PERSONAL HISTORYX. DRUG HISTORYXI. FAMILY HISTORYXII. SOCIO-ECONOMIC HISTORY

I. PATIENT’S PROFILE

1) Name2) Age (Date of Birth)3) Sex4) Address of parents5) Date of admission

II. PRESENTING COMPLAINTS (Use parents’ own words + chronological order)

III. HISTORY OF PRESENT ILLNESS

1) Enquire as to when patient was last entirely well?2) Presenting complaints

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 symptomsg) Treatment if any

3) Systemic inquirya) 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, wheeze, frequent chest infections, history of aspiration, hemoptysis)

d) Gastrointestinal system (abdominal pain, vomiting, jaundice, diarrhea/constipation, blood in stools)

e) CNS (fits, syncope/dizziness, headache, visual problems, numbness/unpleasant sensations, weakness/frequent falls, incontinence)

f) Genitourinary system (stream, dysuria, frequency, nocturia/enuresis, incontinence, hematuria)

g) Rheumatological system (limp, joint swelling, hair loss, skin rash, dry mouth/mouth ulcers, dry or sore eyes, cold extremities)

IV. BIRTH HISTORY (Important in neonatal, genetic or developmental case)

ANTENATAL HISTORY (H/O PREGNANCY)

1) H & N status (Health and nutritional status of mom during pregnancy)

2) Illness during pregnancy (HTN, DM, pre-eclampsia, antepartum haemorrhage)

3) Infections during pregnancy (rubella, UTIs, syphilis, T.B.)4) Drugs (iron, multivitamin, other drugs with dose, duration and at

which time of gestation)5) X-ray (h/o irradiation in 1st trimester)6) TT (maternal vaccination against tetanus)7) Past obstetric (problems with previous pregnancies, stillbirths,

miscarriages, birth weight of previous children, prematurity, blood transfusions)

NATAL HISTORY (H/O DELIVERY)

1) Place of delivery (hospital/home)2) Conducted by (dai/trained health visitor/doctor)3) Sterilization technique for instruments4) Gestation time (length)5) Rupture time (time of rupture of membranes)6) Labour time (duration)7) Presentation and type of delivery (SVD, forceps, vacuum extraction

or C-section)8) Sedation/analgesics during labour9) Complications (abnormal bleeding)

POSTNATAL HISTORY

1) 1ST cry (immediately/cyanosed/apneic)2) Basic problems (need for resuscitation, problem with respiration,

sucking/swallowing)3) Birth weight4) Birth injury5) Convulsions, cyanosis, jaundice, fever, rash6) Procedures (exchange transfusion, umbilical artery catheterization,

drugs)

V. FEEDING HISTORY (Significant in child < 2 years , anemic or malnourished)

1) Onset of feeding (after how many hours)2) Type of feed

Breast-fed (duration) Bottle-fed (at what age, composition of formula, amount, frequency, dilution)

3) Supplements (vitamin, iron)4) Weaning (when, what, amount, frequency)5) Current diet/change in diet during illness

VI. IMMUNIZATION (check vaccination card * )

1) Types of Vaccinations given2) Age at which started and by whom3) Doses & adverse effects

VII. DEVELOPMENTAL HISTORY

1) Achieving age of various milestones Smiling Ability to hold neck Sit Crawl Stand Walk Talk Control of bladder and bowel

2) Compared with normal for this age

VIII. PAST HISTORY

1) Significant illness in the past (esp. diarrhea, respiratory infections, fevers, fits, jaundice)2) History of similar complaints in the past

IX. PERSONAL HISTORY

1) Particular habits of child2) Details of class, school and interest in studies3) Any missed school attendance4) Behavior of the child at school and relationship with other children

X. DRUG HISTORY

1) Any medications used (frequency, dose, adverse effects)2) Allergy to any drug3) H/o Mom drug usage ** (in neonate or breast fed baby)

XI. FAMILY HISTORY

(Important in chromosomal, hereditary, infectious diseases)

1) Age of mother and father? How long married?2) Consanguinity ***3) Parents’ health (present and past)4) Siblings

Number Age and sex Illness Any death (cause if known or symptoms of illness before death) Stillbirths, miscarriages

5) Grand parents’ health (esp. if living with family)6) Health of uncles, aunts and their children (if inherited disorder suspected)7) DO MAKE A FAMILY TREE ***

XII. SOCIO-ECONOMIC HISTORY

1) Parents’ education and occupation2) Family income3) House (made of, persons living, size)4) Cleanliness and general hygienic conditions 5) Source of drinking water6) Any pets at home