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Pediatric Histotry Format

This document outlines the typical format for documenting a pediatric patient's history, including sections on identification, chief complaints, history of present illness, past medical history, perinatal and developmental history, family history, socioeconomic status, nutrition, immunizations, physical exam, investigations and care plan. The history focuses on gathering details about the current illness, past medical issues, birth, development, family, social factors, nutrition, vaccines and review of body systems. The physical exam includes vital signs and assessment of individual organ systems. Relevant tests and treatment plan are also documented.

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13K views4 pages

Pediatric Histotry Format

This document outlines the typical format for documenting a pediatric patient's history, including sections on identification, chief complaints, history of present illness, past medical history, perinatal and developmental history, family history, socioeconomic status, nutrition, immunizations, physical exam, investigations and care plan. The history focuses on gathering details about the current illness, past medical issues, birth, development, family, social factors, nutrition, vaccines and review of body systems. The physical exam includes vital signs and assessment of individual organ systems. Relevant tests and treatment plan are also documented.

Uploaded by

Archana
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Pediatric history format

Identification (ID):
 Name
 Age/Date of Birth
 Sex
 Religion
 IPD no.
 Informant ( Reliability)
 Parent’s name, age, address, education,
 Provisional clinical impression
 Final diagnosis

Chief Complaints (CC):


 Symptoms at the time of admission, Duration in Chronological order

History of Presenting Illness (HPI):


 Symptoms: Location, quality, quantity, aggravating and alleviating factors
 Time course: Onset, duration, frequency, change over time
 Rx/Intervention: Medications, medical help sought, other actions taken
 Etiology and risk factors

History of Past Illness:


 Date and Interventions for: Respiratory tract infections, Gastrointestinal infections,
Previous similar episodes, Any significant disease, accidents or injuries, Foreign body
 Hospitalizations
 Surgeries

Perinatal History:
 Pregnancy (Antenatal): Gravida/Para status, Maternal age, Duration, Exposures
(medications, alcohol, tobacco, drugs, infections, radiation), Complications (Bleeding,
Diabetes, Hypertension), Problems with previous pregnancies, Occurred on contraception?
Planned?
 Labor and Delivery (Natal): Length of labor, Rupture of membrane, Fetal movement,
Medications, Presentation, Mode of delivery, Assistance (Forceps, vacuum), Complications,
APGARs, Immediate breathe/cry, Oxygen requirement, Intubation and duration
 Neonatal (Postnatal): Birth height and weight, Abnormalities, Injuries, Length of
hospital stay, Complications (Respiratory Distress Syndrome, Cyanosis, Anemia, Jaundice,
Seizures, Anomalies, Infections), Behavior
Development History:
Anthropometric assessment:
Anthropometric Patient range Normal range Remark
parameters
Height
Weight
Head circumference
Chest circumference
Mid upper arm
circumference

Developmental milestone:
 Assess each of the 4 areas individually in order: Gross motor, Fine motor, Language,
Personal social
 Ask the milestone which you expect the child to achieve at that age
 If the child has acquired these functions, the development can be considered as normal.
State as follows: The development of this __ months old child matches the chronological
age in all 4 spheres of development.
 If the child has not acquired the desired function, ask for a function that the child would
have achieved by an earlier age, in that particular sphere of development. State as follows:
The development of this __ months old child in the __ area corresponds to a chronological
age of between __ to __ months.
 Try to find out etiology through perinatal, family or social history, if there is
developmental delay

Family history:
 Family tree
 Family description
Name Age/sex Relation with Health status Remark
patient

Socioeconomic status history:


 Parent’s education and occupation, living arrangements, pets, water supply, lead exposure
(old house, paint), Smoke exposure, religion, finances, family dynamics, risk taking
behaviors, school/daycare, other caregivers

Nutritional history:
 When was the 1st feed given?
 Whether baby received any prelacteal feeds?
 How many times breast-feed is given in last 24 hours?
 How many night feeds were given?
 *Does the child receive any other food or drink in addition to breastfeeds? If yes which
food and drink?
 If animal milk/formula milk: how many times in last 24 hours? Dilution?
 What is being used to feed the child if baby is receiving feed other than breastfeeds:
cup/spoon/bottle?
 How feeding bottle/cup is prepared: washing? Boiling?
 How many times baby is passing urine in 24 hours?
 What is the color of urine?
 Ask mother if she has any pain during breastfeeding?

Immunizations:
 up to date, reactions

Physical examination:
Review of Systems (ROS):
 General—fever, activity, growth
 Head—trauma, size, shape
 Eyes—erythema, drainage, acuity, tearing, trauma
 Ears—infection, drainage, hearing
 Nose—drainage, congestion, sneezing, bleeding, frequent colds
 Mouth—eruption/condition of teeth, lesions, infection, odor
 Throat—sore, tonsils, recurrent strep pharyngitis
 Neck—stiff, lumps, tenderness
 Respiratory—cough, wheeze, chest pain, pneumonia, retractions, apnea, stridor
 Cardiovascular—murmur, exercise intolerance, diaphoresis, syncope
 Gastrointestinal—appetite, constipation, diarrhea, poor suck, swallow, abdominal pain,
jaundice, vomiting, change in bowel movements, blood, food intolerances
 GU—urine output, stream, urgency, frequency, discharge, blood, fussy during
menstruation, sexually active
 Endocrine—polyuria/polydipsia/polyphagia, puberty, thyroid, growth/stature
 Musculoskeletal—pain, swelling, redness, warmth, movement, trauma
 Neurologic—headache, dizziness, convulsions, visual changes, loss of consciousness,
gait, coordination, handedness
 Skin—bruises, rash, itching, hair loss, color (cyanosis)

Summary of the case:

Investigation:
Sr. Name of examination Patient value Normal value Remark
No

Medications:
Sr. no Name of drugs Dose / time Route Action
Care plan

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