Pediatric History

Patient Profile
Name: _________________________

Age: _______________________

Gender: Male/Female

Address: ____________________

Date: __________________________

MR#: _______________________

History given by:

__________________
History taken in: OPD / IPD

Presenting Complaint:
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History of Presenting Complaint
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Review of System
G ENERAL : 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,
bedwetting
CNS: 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,
hyperactivity
MSS : muscle aches, bone pain, joint swelling, limitation of joint movement, disturbance of gait
S KIN : rash, unusual marks, birthmarks
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Past Medical History
MEDICAL: DM, epilepsy, TB, hepatitis, asthma, cancer, allergies,
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S URGICAL : trauma, blood transfusion, surgery,
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Birth History
Prenatal

Illness, infections, drug intake, trauma, abnormal bleeding

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Previous number of pregnancies:
Folic and iron intake, tetanus injection
______________
And outcome: _____________________________
Natal
Place of delivery: hospital/home/other,
conducted by _______________

Condition of baby at birth:

______________________

Mode: vaginal, C-section

Resuscitation measures, instrumentation done,

complications during delivery

Birth Weight: ________________ kg

Gestation:
____________________________________

Length of labour:

Maternal fever, premature rupture of membranes

_____________________________
Postnatal

Illness in neonatal period: ______________________________________________________________________________

Immediate cry
Treated on special care baby unit, vitamin K

given
Feeding History

Breast feeding
o Started: ___________________
o Frequency: ________________
o Total duration: _____________

o
o
o
o

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

Jaundice, cyanosis, respiratory distress

Duration of stay after delivery:
______________

o
o
o
o

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

Current diet:
______________________________________
______________________________________

Immunization History:
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_______________
Medication History:
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____________________
Development History

Social smile (1

Neck holding (3

Sitting (6

Hold objects in
month)
month)
month)
hands (6 month) ________
________
________
________

Crawling (10
months)
________

Standing (1 year)
________

Talking single
words (1 year)
________

Combining 2 words
(2 year)
________

Dry by day (2
year)
________

Dry by night (3
year)
________

Family History
Age of mother: _________________
DM, HTN, MI, stroke, TB, hepatitis, asthma, cancer,
other

Walking (15
months)
________

Age of father: ________________

Siblings (with ages):
__________________________________

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_
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

Sanitary conditions:

water/well water/boiled
Personal History

Behavior of child at home/school:

_________________________________

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Habits and interests:

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School performance:
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Examination
GENERAL AND PHYSICAL EXAMINATION
Appearance: _________________________________________________________________________________________________
Vitals

Pulse: ___________ bpm

Temperature: _________

GCS: _________

Head circumference:
______________

Respiratory rate:
__________ /min

Weight: _________ kg

Blood pressure: ______ / ______

mmHg

Height: ____________________

percentile: _________

percentile: _________

percentile: _________
H EAD AND NECK : molding, cephalohematoma, caput succedaneum, scalp lacerations, abnormal pigmentation, scar
marks, puffiness, periorbital edema, exophthalmos, pallor, jaundice, goiter
MOUTH : plaques, white patches, spots, mouth ulcers, cleft lip, cleft palate, tongue: _____________
H ANDS : abnormal pigmentation, scar marks, clubbing, koilonychia, palpable nodes, palmar erythema, thenar or
hypothenar atrophy, splinter hemorrhages, sweating
S KIN : pallor, rash, petechiae, bruises, decreased capillary refill, skin turgor
EYES : ptosis, squint, nystagmus, subconjunctival hemorrhages, jaundice, cataract, abnormal papillary reflexes
EARS : low-set, wax, boils, tympanic membrane: __________________________________
N OSE : nasal bridge depression, nasal discharge, deviated nasal septum, patency of nostrils: _____________
LYMPH N ODES : submental, submandibular, anterior cervical, posterior cervical, preauricular, postauricular,
occipital, supraclavicular, axillary, inguinal
CARDIOVASCULAR EXAMINATION
Inspection

Abnormal pigmentation, scar marks, visible veins, visible pulsations

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Palpation

Apex Beat: ________ intercostal space

Heaves, thrills

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Auscultation

S1+S2: ____________
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RESPIRATORY EXAMINATION
Inspection

Chest shape:
____________________________________

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

Chest movements:
________________________________

Palpation

Trachea:
________________________________________

Chest wall movements:

____________________________

Chest expansion:
_________________________________

Vocal fremitus:
__________________________________

Percussion

Resonance: __________________________________________________________________________________________

Auscultation

Breath sounds: _______________________________________________________________________________________

ABDOMINAL EXAMINATION
Inspection

Scar marks pigmentation, abdominal distension,

visible veins

Umbilicus:
______________________________________

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Palpation

Hepatomegaly, splenomegaly, kidneys palpable, guarding, abdominal rigidity

Tenderness:
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Percussion

Liver span: ______________

Shifting dullness: ______________

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Auscultation

Bowel sounds: increased/decreased/normal

Renal bruit, splenic rub, aortic bruit

CNS EXAMINATION

Cranial nerves:
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Motor examination:
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Sensory Examination:
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Reflexes:
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Cerebellar function:
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OTHER EXAMINATION (_____________________________________________________________)

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Investigations
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_____________________

___________________

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Differential Diagnosis
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Plan/Treatment
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