History Taking in Pediatric

8/6/2019 History Taking in Pediatric

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HISTORY TAKING IN PEDIATRIC

By: Amie-Anne Augustine (060100841)


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On meeting patient:

Introduce yourself and get down to the same level

as the patient

Identify the patient (find out name, date of birth,

age, sex, religion, and address)

Confirm the relationship of the accompanying adult.


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Give a prompt to allow the parent to have their

say, e.g. what is your main worry?

Listen carefully and patiently and then follow up

with specific questions to elicit the full details of the

presenting symptoms.


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Infections: age, types, number, severity

Contagious disease: age, complications of measles,

rubella, chickenpox, mumps, pertussis, diphteria, scarlet

fever, others Past hospitalization, including operation, age,

complications

Accidents and injuries: nature, severity, sequelae.

Allergies: foods? Drugs? Environmental agents? Current medications

Immunization and skin tests. List date and type.


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1. Antenatal

Determine health of the mother during pregnancy. Include exposure toradiation, drugs, and infection. Include mothers previous pregnancyhistory.

2. Natal Duration of pregnancy

Birthweight

Duration of labor

Type of delivery and presentation

Sedation and anesthesia (if known) State of infant at birth

Resuscitation required

Onset of respiration

First cry


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3. Neonatal

Ascertain condition of baby after birth. Determine

if problems were present, such as cyanosis,

jaundice, convulsions, feeding difficulties. A

question about the babys length of stay in the

nursery can provide much information. Determine

the need for special care, such as an incubator,transfusions, medications, and bili light.


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1. Motor and mental development


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2. Physical growth

Gather any available data about sequential

weights and lengths for later plotting on growth

charts.


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Determine the general status of the childs appetite

Breast or formula : type, duration, time of weaning,

difficulties. Be specific about how much milk or

formula the baby receives.

Vitamin supplements: type, when started, amount,

duration.

solid foods : when introduced, how taken, types.


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Father and mother (age and condition of health). Marital relationships. Siblings. Age, condition of health, significant previous

illnesses and problems. Stillbirths, miscarriages, abortions; age at death and

cause of death of immediate members of family. Tuberculosis, allergy, blood dyscrasias, mental or

nervous diseases, diabetes, cardiovascular diseases,kidney disease, rheumatic fever, neoplastic diseases,

congenital abnormalities, cancer, convulsive disorders,

others.


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Daily activities

History of travelling


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Documents

History Taking in Pediatric