Pediatric History Taking 1. Informant -relationship to patient & % reliability 2.

Patient's profile -name -age/sex -address -nationality -religion -# of admissions/consultations -date of admissions -chief complaint & duration [Link] Medical History a. Prenatal -mother's OB score GPTPAL -prenatal checkup -general condition -age of mom - planned pregnancy - financial worries - physical illness (infection, HTN, DM, Asthma, bleeding) - mom's previous hospitalization and illnesses - prior miscarriages/stillbirths -toxemia, hormones, radiation -perception about pregnancy -diet, therapy, medications, vitamins -habits (alcohol, smoke) -threatened abortion -prenatal risk factors for attachment: -recent death of loved one -previous loss or serious illness of another child -prior removal of a child -hx of depression/serious mental illness -hx of infertility or pregnancy loss -troubled relationship with parents -financial stress/job loss -marital discord or poor relationship with the other parent -recent move or no community ties -no friends or social network -unwanted pregnancy -no good parenting model -drug/alcohol abuse -extreme immaturity b. Natal/Birth History -duration & circumstances of labor (presence of doula?) -outcome of the baby -where? home, lying in, hospital delivery -who assisted the delivery? doctor, midwife, nurse, etc. -type of delivery? NSVD, VBAC, C/S -complications -medications given to mother -assisted delivery? forceps, oxytocin, etc -birth wt -AOG -condition upon birth: meconium staining, jaundice,APGAR score (good cry) -birth rank -medications given to baby (vitamin K, BCG, eye ointment, HepB vaccine) -latched-on (1-4hrs)? or parenteral nutrition? -duration of hospitalization c. Postnatal History

1. Immunizations -at birth -BCG

- 0.05ml ID left deltoid -rxn: keloid scar, suppurative regional adenitis,

disseminated BCG infxn, osteomyelitis -HBV 1 - 0.5ml IM thigh -rxn: arthralgia, neurologic rxns -2nd month -OPV 1 - 2 drops PO -rxn: paralytic polio -DPT 1 - 0.5ml IM thigh -rxn: fever restlessness, irritability, local inflammation -HBV 2 -0.5ml IM thigh -rxn: arthralgia, neurologic rxns -HiB 1 - 0.5ml IM thigh - rxn: pain, redness, swelling at injection site, fever, irritability -4th month -OPV 2 - 2 drops PO -rxn: paralytic polio -DPT 2 - 0.5ml IM thigh -rxn: fever restlessness, irritability, local inflammation -HiB 2 - 0.5ml IM thigh - rxn: pain, redness, swelling at injection site, fever, irritability -6th month -OPV 3 - 2 drops PO -rxn: paralytic polio -DPT 3 - 0.5ml IM thigh -rxn: fever restlessness, irritability, local inflammation -HBV 3 -0.5ml IM thigh -rxn: arthralgia, neurologic rxns -HiB 3 - 0.5ml IM thigh - rxn: pain, redness, swelling at injection site, fever, irritability -12th month -MMR - 0.5ml SQ -rxn: -mumps: febrile seizures, nerve deafness, encephalitis, rash, pruritus -measles: fever & rash 5-10 days after dose -rubella: arthralgia, lymphadenopathy, mild rash 2-4wks later -other vaccines: -Human Papilloma Virus Vaccine - minimum age: 9 years old -Rotavirus Vaccine - minimum age: 6 weeks -Pneumococcal Vaccine - minimum age: 6 wks (PCV) and 2yrs (PPSV) -Influenza Vaccine - minimum age: 6mos (TIV) and 2 years (LAIV) -HepA vaccine - minimum age: 23 months (2 doses 6 months apart) -Varicella vaccine - minimum age: 12 months -Meningococcal vaccine - minimum age: 2 years 2. Illnesses & exposure to other illnesses, Injuries, Hospitalizations 3. Medications 4. Blood type 5. Newborn screening? results? -congenital hypothyroidism -congenital adrenal hyperplasia -galactosemia -phenylketonuria

-G6PD deficiency -homocystenuria 6. Nutrition -frequency (ave: q2-3hrs) & duration per feeding -usual time of feeding -middle-of-the-night feeding (3-6wks)? how often? -no late evening feedings (beyond 3-6wks) -eats 3meals/day + snacks (9-12mos) - when was the regular schedule established? -# of feedings/day (ave: 6-9 feedings/24hrs) -does the infant suck well -0-3rd day of life = not avid suckers -4th-5th day = starts becoming good nursers -burping procedure (1 or more times during feeding & 5-10mins after feeding) -weight changes -end of 1st wk --> wt loss -end of 2nd wk --> gain wt -kind of feeding -if breastfed: -age started and stopped -duration (months) as a sole source of nutrition -duration (months) with complementary feeding -has there been supplemental feeding -use of breast pumps? -alternate breasts? -reaction to milk (gastric distress, diarrhea) -maternal condition during breastfeeding (inverted nipples, mastitis, infxn, septicemia, active TB, typhoid fever, breast CA, malaria, psychosis, substance abuse) -if bottle fed: -composition of formula (1:1) -volume (max: 1 qt or 960ml of formula/day) -brand and type of milk -age started -weaning: -age started? (4-6mos) -usual food? -list of initial weaning foods (cereals, fruit juice, pureed fruits & vegetables) -list of food with high allergenic potential (cow's milk, eggs, fish, nuts, soybeans) -how was the child weaned? 1. start small amts (1-2tsp) and gradually increase amt 2. give the food after a feed 3. wait 3-4 days before introducing new food 4. avoid large volumes of fluid before meals 5. give fluids after meals -vitamins -vitamin K1 (1mg at birth) -fluoride (10mg daily from 0-6months) -vitamin D (200IU/day from 2months) -iron (starting 4-6months) 7. Growth & development (see scanned table) 4. Psychosocial History -sleep: patterns, hours/day -elimination: frequency, color & consistency -household composition -caregiver?

-activities of daily living -family income -for older children: -smoking, drugs, alcohol -education / occupation? -exercise -stressors and coping mechanisms -sexual hx 5. Family History -both parents and siblings are alive & healthy? -heredofamilial dses (hypertension, coronary artery diseases, elevated cholesterol, stroke, diabetes, thyroid/renal dses, arthritis, tuberculosis, asthma or lung diseases, headache, seizure, mental illness, suicide, cancer) 6. History of Present Illness