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History Taking in Pediatrics-How to Take History In Pediatrics

history taking from a baby,child,in pediatrics
Use the following format while taking history from a child/ baby or neonate in Pediatrics department.
NAME:                                                                                   AGE                                      SEX                                                       
ADDRESS                                                                              ADMITED FROM                                                                            
ON  ( DATE )                                                                                      


ASSOCIATED SYMPTOMS.                                                                                         
EXAMINE THROAT:                                                                                                      

CHANGE IN FEEDING DURING ILLNESS.                                                                 
DIFFICULTY IN FEEDING.                                                                                           
REFUSAL TO FEEDING                                                                                                

FREQUENCY OF VOMITING                                                                                       
FORCE OF VOMITING                                                                                                  
RELATIONSHIP OF VOMITING WIH FEEDING                                                         
COLOR AND CONTENT OF VOMITUS                                                                      

Duration of Diarhea :                                                                                                          
Contents of stool ( blood or mucus )                                                                                    
Cry more often?                                                                                                    
Cry less often ?                                                                                                     
Cry is normal ?                                                                                                     
Dry or wet:                                                                                                           
Time of day                                                                                                           
Relation with feeding?                                                                                            
Accompanied by wheeze of fever?                                                                         

Difficult Breathing?
Age of onset?                                                                                                            
Relation with activity?                                                                                               
Relation with feeding?                                                                                               
Presence of cough stridor wheeze or cyanosis                                                         
Site and distribution:                                                                                    
Type: (macular, papular,vesicular, pustular,purpuric)                                        
Presence of itching.                                                                                                

Age of onset:                                                                                                                
Episodic or persistent:                                                                                                 
Associated symptoms: ( respiratory distress )                                                              
Age of onset:                                                                                                              
Associated symptoms:                                                                                               

Lethargy and Unconciousness                                                                                                                                                                                                                                                      
Posture and Gait:                                                                                                        
Neck holding and sitting.                                                                                  
Standing and walking                                                                                                     
Usual body movements.                                                                                                  

Involuntary movements.
Age of onset                                                                                                                 
Any relation with febrile illness                                                                                      
Progress since onset.                                                                                                   
History of Birth
Inquire about mother disease:
Diabetes mellitus                                                                                         
Swelling of feet                                                                                           
Infections (TB , rubella )                                                                               
Drug intake ( dose, duration and time of gestation)                                            

Duration of gestation.                                                      
Place of delivery                                                            
Duration of labor                                                            
Mode of delivery                                                           
Complications during delivery                                                                                 

First cry (immediate or late )                                                                                       
Time of onset of respiration after delivery                                                                   
Any resuscitation giver?                                                                                     
Birth weight                                                                                                        
Birth injury                                                                                                
Feeding difficulty in postnatal period                                                                                                                                     
Jaundice, cyanosis, fits, fever or any other symptoms during neonatal period.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                   
Feeding history:
Time between birth and first feed:                                                                 
Type of feeding ( breast or formula feeding)                                                      
Frequency of feeding ( quantity and dilution of bottle feed)                                        
Age at which solids are started:                                                                      
Current feeding practices before current illness                                                 
Any change in food intake during illness.                                                           

Visit to vaccination center?                                                                         
Type of Vaccine?                                                                           
When and given by whome?                                                             
Complete of incomplete?                                                                

Developmental History:
Smile?                                   Hold his neck?                                   Rollover                               Start responding to voice                                             Sit up with support and without support?                                                             Crawl?                                  Start to walk with and without support                                                                      Talk(single word, sentence)                                                                                                                                                                       
Run                                                        Start feeding with hand                                                                                                               
Indicate toilet needs                                                                                                                                                                     
Past History:
Medical ( respiratory infections, diarrhea, fevers fits etc )
Family History:
Age of the mother and father?
Parent’s health (present and past)
Siblings: (age and sex, Illnesses, any deaths , still births miscarriages)
Grand parent’s health:                                                                                                                                                                 
Inherited disorders?                                                                                                                                                                                                                                                                                                                                                                                      
Consanguinity (blood relation between parents eg. Cousin marriage, second cousin marriage)
Social History
Parent Education :                                                                                            
Parent’s Occupation:                                                                                    
Family Income:                                                                                                  
Person living in the house:                                                                                  

Personal History:
Particular habits of child:                                                                                       
Interest in studies:                                                                                         
Behavior of child                                                                                             
Environmental history:
Size of house:                                                                                                   
No of inhabitants                                                                                            
Cleanliness and general hygienic conditions                                                          
Source of drinking water                                                                                      

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