Anamnesis(recollection, a patient case history)

Sugianto

Identifying information

• Age• Sex• Date of interview• Informant• (birthdate, race, religion, nationality)

• Chief complaint• Present illness• Review of systems• Past history• Family history• Birth history• Immunizations• Growth and development• Feeding• Physical examination

1. Chief complaint

The specific reason for the child’s visit the clinic or hospital.

6 guidelines determine appropriate recording of the chiefcomplaint:1. it is limited to a brief statement,2. it is restricted to one or two symptoms,3. it refers to a concrete complaint,4. it is recorded in the child’s or parent’s own words,5. it is avoids the use of diagnostics terms or translations,6. it state the duration of the symptoms(e.g. runny nose for 5

d., cough for 3 d)

2. Present illness

A narrative of the chief complaint from its earliest onset through its progression to the present.4 major components are:• details of onset,• complete interval history,• present status,• reason for seeking help now.

2. Present illness

Review of systems1. General overall state of health, unexplained weight gain or loss, fevers, chills, night sweats(unrelated to climatic conditions), frequent infections.2. Integument pruritus, jaundice, cyanosis, pallor, purpura, petechiae, edema, rash, eruptions.3. Head headaches, dizziness, injury, a small head, a large head.4. Eyes poor vision, glasses, strabismus, inflammation, diplopia.

2. Present illness

Review of systems5. Nose epistaxis, nasal obstruction(difficulty in breathing).6. Ears earaches, ear discharge, defective hearing, tinnitus, vertigo 7. Mouth and throat mouth breathing, gum bleeding, toothaches, stomatitis, gingivitis, trismus, difficulty in sucking and swallowing 8. Neck pain, limitation of movement, stiffness, torticollis (difficulty in holding head straight), thyroid enlargement, enlarged nodes or other masses.

2. Present illness Review of systems 9. Chest and respiratory chest pain, breast enlargement, discharged, masses, enlarged axillary nodes, cough, wheezing, shortness of breath at rest or on exertion, difficulty in breathing, stridor, sputum production, hemoptysis, hoarseness, history of pneumonia, bronchitis.10. Cardiovascular cyanosis, fatigue on exertion, rheumatic

fever.11.Gastrointestinal nausea, vomiting( frequency, amount relation to feeding or to cough, color, forcefulness), belching,

flatulence, dysphagia, abdominal pain, hematemesis, hematochezia, melena, stools(constipation, diarrhea, color, blood, size, consistency).

2. Present illness

Review of systems12. Genitourinary pain on urination(dysuria), hematuria, polyuria, enuresis. 13. Gynecologic menarche, vaginal discharge, pruritus14. Musculoskeletal weakness, muscle pains or cramps, fracture, deformity15. Neurologic seizures, tremors, hypotonia, chorea, delirium, temper tantrum. 16. Endocrine excessive sweating, excessive thirst

3. Past history

The past history contains information relating to all previous aspects of the child’s health status(infectious diseases, hospitalizations or major illnesses, operations, trauma, fractures, head injuries, allergies, other).

4. Family historyFamilial diseases and congenital anomalies.

5. Birth history

includes all data concerning• the mother’s health during pregnancy(maternal illnesses,

bleeding, toxemia, X-rays, drugs during pregnancy, duration of pregnancy).

• the labor and delivery( duration of labor, type of delivery, e.g. cephalic, breech, forceps, caesarian, anesthetic, where born).

• the infant’s condition immediately after birth( birth weight, respiration, resuscitation, cyanosis, jaundice, other problems, incubator, oxygen, age at discharge from hospital).

6. ImmunizationsBCG, Hepatitis B, Diphtheria/pertussis(cellular or acellular)/tetanus, polio, Measles(give number of administrations of each).

7. Growth and developmentThe most important previous growth patterns to record are:• approximate weight at 6 months, 1 year, 2 years and 5 years of

age,• approximate length at ages 1 and 4 years, and dentition,

including age of onset, number of teeth, and symptoms during teething.

Developmental milestones include:• age of holding up head steadily• age of sitting alone without support,• age of walking without assistance,• age of saying first words with meaning• school performance• interaction with other children, peers, and adults.

8. Feeding

• breast, how long?• bottle• type of milk, composition of formula.• feeding schedule• total amount of milk per day• age at starting cereals, vegetables, fruits, meat, eggs• how often taken, especially sources of iron, ( e.g., red meat,

fortified infant cereals)• vitamin- preparation dose, how long given.• feeding problems