Pediatric HistoryPatient Profile

Name: _________________________

Age: _______________________

History given by: __________________

Gender: Male/Female

Date: __________________________Address: ____________________MR#: _______________________History taken in: OPD / IPD

Presenting Complaint:____________________________________________________________________________________________

____________________________________________________________________________________________

____________________________________________________________________________________________History of Presenting Complaint

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Review of System

General: change in weight, loss of appetite, weakness, fatigue, fever

ENT: hearing loss, ear infection, ear discharge, difficulty breathing, nasal discharge, snoring, nasal bleeding, enlarged lumps or glands, sore throat, dental problems, mouth ulcers

GIT: nausea, dysphagia, regurgitation, flatulence, heartburn, vomiting, hematemasis, abdominal pain, abdominal distention, abnormal bowel habit, constipation, diarrhea, abnormal stool, rectal bleeding, incontinence

Resp: hemoptysis, hoarseness, wheezing, chest pain

CVS: dyspnea, paroxysmal nocturnal dyspnea, orthopnea, cyanosis, chest pain, dizziness

UGS: loin pain, poor stream, dribbling, hesitancy, dysuria, urgency, hematuria, polyuria, incontinence, nocturia, bedwettingCNS: behavioral changes, depression, memory loss, anxiety, tremor, loss of consciousness, fits, muscle weakness, sensory disturbances, parasthesias, dizziness, change of smell, vision or hearing, headaches, seizures, hyperactivityMSS: muscle aches, bone pain, joint swelling, limitation of joint movement, disturbance of gait

Skin: rash, unusual marks, birthmarks

_______________________________________________________________________________________________________________Past Medical HistoryMedical: DM, epilepsy, TB, hepatitis, asthma, cancer, allergies, ________________________________________________________________________________________________________________________________________________________________________________Surgical: trauma, blood transfusion, surgery, __________________________________________________________________________________________________________________________________________________________________________________________________Birth History

Prenatal

Illness, infections, drug intake, trauma, abnormal bleeding_________________________________________________________________________________________________________________

Previous number of pregnancies: ______________

And outcome: _____________________________ Folic and iron intake, tetanus injection

Natal Place of delivery: hospital/home/other,

conducted by _______________ Mode: vaginal, C-section

Condition of baby at birth: ______________________

Gestation: ____________________________________ Resuscitation measures, instrumentation done, complications during delivery

Birth Weight: ________________ kg

Length of labour: _____________________________ Maternal fever, premature rupture of membranes

Postnatal

Illness in neonatal period: ______________________________________________________________________________ Immediate cry Jaundice, cyanosis, respiratory distress

Treated on special care baby unit, vitamin K given Duration of stay after delivery: ______________

Feeding History Breast feeding

Started: ___________________ Frequency: ________________ Total duration: _____________ Artificial feeding

Type of milk: ____________________ Dilution: _______________________ Volume: ________________________ Frequency of foods: ______________

Weaning

Started: _________________________ Type: ___________________________ Frequency: _______________________ Amount: _________________________

Current diet: ______________________________________ ______________________________________

Immunization History: ______________________________________________________________________________________________________________________________Medication History: ___________________________________________________________________________________________________________________________________

Development History

Social smile (1 month)

________ Neck holding (3 month)

________

Sitting (6 month)

________

Hold objects in hands (6 month) ________

Crawling (10 months)

________

Standing (1 year)

________

Talking single words (1 year) ________

Walking (15 months) ________

Combining 2 words (2 year)

________ Dry by day (2 year)

________

Dry by night (3 year)

________

Family History

Age of mother: _________________

Age of father: ________________

DM, HTN, MI, stroke, TB, hepatitis, asthma, cancer, other

____________________________________________________

Siblings (with ages): __________________________________

Consangious marriage: yes/no

Diseases or deaths in family: __________________________

Social History

Educational status of parents: Mother ___________ Father ___________ Monthly income: ____________Rs.

Environment History

Type of house/no. of rooms/no. of people living: _______________________________________________________________________

Water supply: public filter/house filter/tap water/well water/boiled Sanitary conditions: _________________________________

Personal History

Behavior of child at home/school: _____________________________________________________________________________________ Habits and interests: ________________________________________________________________________________________________ School performance: _______________________________________________________________________________________________ExaminationGENERAL AND PHYSICAL EXAMINATIONAppearance: _________________________________________________________________________________________________

Vitals

Pulse: ___________ bpm Respiratory rate: __________ /min Blood pressure: ______ / ______ mmHg

Temperature: _________ GCS: _________

Head circumference: ______________

percentile: _________ Weight: _________ kg percentile: _________ Height: ____________________

percentile: _________

Head and Neck: molding, cephalohematoma, caput succedaneum, scalp lacerations, abnormal pigmentation, scar marks, puffiness, periorbital edema, exophthalmos, pallor, jaundice, goiterMouth: plaques, white patches, spots, mouth ulcers, cleft lip, cleft palate, tongue: _____________Hands: abnormal pigmentation, scar marks, clubbing, koilonychia, palpable nodes, palmar erythema, thenar or hypothenar atrophy, splinter hemorrhages, sweatingSkin: pallor, rash, petechiae, bruises, decreased capillary refill, skin turgorEyes: ptosis, squint, nystagmus, subconjunctival hemorrhages, jaundice, cataract, abnormal papillary reflexes

Ears: low-set, wax, boils, tympanic membrane: __________________________________

Nose: nasal bridge depression, nasal discharge, deviated nasal septum, patency of nostrils: _____________

Lymph Nodes: submental, submandibular, anterior cervical, posterior cervical, preauricular, postauricular, occipital, supraclavicular, axillary, inguinalCARDIOVASCULAR EXAMINATIONInspection Abnormal pigmentation, scar marks, visible veins, visible pulsations____________________________________________________________________________________________________________Palpation Apex Beat: ________ intercostal space Heaves, thrills

____________________________________________________________________________________________________________Auscultation S1+S2: ________________________________________________________________________________________________________________________RESPIRATORY EXAMINATIONInspection Chest shape: ____________________________________ Chest movements: ________________________________

Scar marks, pigmentation, visible veins, use of accessory muscles, nasal flaring

Palpation Trachea: ________________________________________

Chest expansion: _________________________________ Chest wall movements: ____________________________

Vocal fremitus: __________________________________

Percussion Resonance: __________________________________________________________________________________________Auscultation Breath sounds: _______________________________________________________________________________________ABDOMINAL EXAMINATIONInspection Scar marks pigmentation, abdominal distension, visible veins Umbilicus: ______________________________________

_____________________________________________________________________________________________________________

Palpation Hepatomegaly, splenomegaly, kidneys palpable, guarding, abdominal rigidity Tenderness: _________________________________________________________________________________________________Percussion Liver span: ______________ Shifting dullness: ______________

___________________________________________________________________________________________________________

Auscultation Bowel sounds: increased/decreased/normal Renal bruit, splenic rub, aortic bruit

CNS EXAMINATION Cranial nerves: _______________________________________________________________________________________________

Motor examination: ___________________________________________________________________________________________

Sensory Examination: __________________________________________________________________________________________

Reflexes: ____________________________________________________________________________________________________

Cerebellar function: ___________________________________________________________________________________________

OTHER EXAMINATION (_____________________________________________________________)____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Investigations_______________________________________________________________________________________________________

Differential Diagnosis____________________________________________________________________________________________________

Plan/Treatment________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________