CONGENTIAL HEART

DISEASE
SAMPLE peads HISTORY

JIANGXI UNIVERSITY OF TCM

Dr. XYZ
 Name Fathers Age Height Weight Date of birth
name
Gender Ward/Unit Bed No. Address Date & time Mode of
of admission admission

CHIEF COMPLAINTS: (chronological order or priority based)

1.
2.
3.
4.

HISTORY OF PRESENT ILLNESS:

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PAST HISTORY:
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Infectious diseases

Hospitalization

Accidents

Operations

Circumcision

DRUG HISTORY:
PAST CURRENT
BIRTH HISTORY:
ANTENATAL Hx:
Well being during pregnancy
Weight gain during pregnancy
Illnesses: HTN, DM, PET, APH, TB, UTI, Rubella, Hepatitis etc
Drugs
Fe, vitamin supplements
X-ray exposure
T.T. inoculation

PAST OBSTETRIC Hx:

Problems with previous pregnancy
Still births or miscarriages
Birth weights of previous babies
Pre-maturity
Transfusions
Jaundice

NATAL Hx:
Delivery:

At: Home, hospital, other (specify)

By: Dai /midwife, LHV, Doctor, family member

Type: NVD, instrumental, C/section

Presentation:

Umbilical cord:

Labour:

Length: normal, prolonged, precipitate

Analgesia, sedation, oxyticics

Abnormal bleeding

Birth order (if multiple pregnancies)

POSTNATAL Hx:
Whether cried immediately, cyanosed, apneic?
Need for resuscitation at birth?
Problem(s) with respiration, sucking, swallowing
History of convulsions, fever, jaundice, rash
APGAR Score: (appearance, pulse, grimace, activity, respiration)
Congenital anomalies
Drugs
Transfusions
Pattern of crying, sleeping, urination, defecation
MOTHER: PPH, any puerperal disease

FEEDING HX:
Onset of feeding
First feed
Supplements: Type? Quantity?
Breast feeding: Exclusive? Total?
Time of introduction of solid foods? Type?
Weaning: Onset? Type of food?
Any food allergies?
Any difficulties? (regurgitation, colic, diarrhea)

IMMUNIZATION Hx:
Age
Type
Dose
Untoward reactions / adverse effects

DEVELOPMENTAL Hx:
Ages at which milestones were reached:

Smile
Neck holding
Sitting with support
Sitting without support
Crawling
Standing with support
Standing without support
Walking
Babbling
First word
Talking
Bladder & bowel control
Dressing without aid

SOCIAL DEVELOPMENT:
Bonding with parents
Playing games
Attitude: docile, violent, hyperactive, slow, apathetic, curious, (other..specify)

FAMILY Hx:
Age of parents: Mother___________, Father____________
Parental consanguinity?
Diseases in the family: HTN, TB, DM, IDH etc
Any hereditary disorder?
Number of family members?
Family system type? (joint, separate etc)

Pedigree Chart
SCHOOLING Hx:
Performance at school
Relationship with students/teachers

SOCIOECONOMIC Hx:
Parents occupation
Conditions of living
Income
Number of rooms in house
Number of people per room
Sanitation & water supply
Other

GENERAL PHYSICAL EXAMINATION:

General appearance
LOC
Nutritional status
Gross abnormalities
Pallor
Anemia (conjunctival)
Jaundice
Thyroid
Clubbing
Koilonychia
Edema
Cyanosis
Lymph nodes
Pulse
Blood pressure
Temperature
Respiratory rate
Head circumference
Arm circumference
External genitalia
REVIEW OF SYSTEMS (ROS):
SYSTEM INSPECTION PALPATION PERCUSSION AUSCULTATION
RESPIRATION
G.I.T.
CVS

CNS:
Motor_________________________________________________
Sensory _______________________________________________
Gait __________________________________________________
Coordination ___________________________________________
Speech ________________________________________________
Neck stiffness __________________________________________
Kernigs sign ___________________________________________
Reflexes ______________________________________________