Historytaking in pediatrics

8/12/2019 Historytaking in pediatrics

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HISTORY TAKING IN PEDIATRICS

Dr. C.S. Balachandran, Professor,Dr. Chintu Oommen

Rajah Muthiah Medical College & Hospital

Annamalai University


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IDENTIFICATION

Name

Informant

Age Reliability

Sex

Address


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ORDER OF HISTORY TAKING

Chief complaints Chronological order

History of Presenting illness

Past history

Antenatal history I, II, III trimester

Natal history

Post natal history

Developmental history

Immunization history

Diet history

Family history

Socio economic history

Allergic history

Treatment history

Contact history


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CHIEF COMPLAINTS

Fever

Cough

Abdominal pain Diarrhoea

Convulsions

Vomiting


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HISTORY OF PRESENTING ILLNESS

Fever

Duration

Onset

High grade or low grade

Chills and rigors

Evening rise of temperature

Continuous or intermittent


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COUGH

Duration

Onset

Character

Diurnal variation

Associated with sputum

Colour

Quantity Foul smelling

Blood stained


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DIARRHOEA AND VOMITING

Duration

Onset

Frequency of diarrhoea and vomiting

Diarrhoea

Consistency Smell

Colour

Blood & mucous

Perianal excoriation

Vomiting Contents

Blood stained

Projectile or non projectile


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ABDOMINAL PAIN

Site

Type

Severity Radiating or non radiating

Aggravating factors

Relieving factors


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CONVULSIONS

Generalized or localized

H/o Aura

Duration Associated with fever or vomiting

Bowel and bladder incontinence present or not

H/o LOC, Headache Post-ictal drowsiness


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BIRTH HISTORY

Previous obstetric history

Normal delivery or not

Complications Weight of the baby

Deformity present or not

H/o Complications during pregnancy


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FIRST TRIMESTER

Any antenatal check ups (Booked Case)

Last menstrual period date

Fever with rash with painful post auricularlymphadenopathy

History of handling of pets present or not

H/o Exposure to drugs / Irradiation Weight gained by mother


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SECOND TRIMESTER

Quickening felt or not

TT injection given or not

Iron and folic acid tablets USG done or not

Mother had PIH or diabetic mellitus

Bleeding / Leaking PV Antenatal checkup


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THIRD TRIMESTER

Bleeding per vaginum

Any infections

USG done or not H/o of drug intake

H/o of exposure to radiation


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NATAL HISTORY

Child term, preterm or post term

Born hospital or home

Mode of Delivery

Child cried immediately after birth or not

Child passed meconium or not

Any resuscitation done or not

Prolongation of labour

Birth weight


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POST NATAL HISTORY

Child developed icterus or cyanosis

Child breast fed or on artificial feeds

History of convulsions Weaning foods

Which day umbilical cord fell down

Feeding problems


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DEVELOPMENTAL HISTORY

Gross motor head holding, rolling over

Fine motor palmar grasp

Language

mono syllabus, bi syllabus Personal and social recognizing mother


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IMMUNIZATION HISTORYAGE VACCINE

Birth-15 days BCG,OPV

zero dose,Hepatitis B Vaccine 1stdose

6 weeks-8 weeks DPT 1stdose,OPV 1stdose,

Hepatitis B Vaccine 2nddose

10 weeks - 12 weeks DPT 2nddose,OPV 2nddose.

14 weeks - 16 weeks DPT 3rddose,OPV 3rddose

6 months - 9 months Hepatitis B Vaccine 3rddose

9 months (Completed) OPV- 4thdose,Measles vaccine.

15 months - 18 months MMR (Measles, Mumps, Rubella)

DPT 1stBooster dose,

OPV 1stBooster dose.

5 years DPT 2ndBooster, OPV 2ndBooster

10 years TT 3rdBooster dose,

Hepatitis B Vaccine Booster dose.

15 16 years TT 4thBooster dose.


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Birth 15 days BCG + OPV (zero dose) Hepatitis B 1stdose

6-8 weeks OPV1 + DPT1 + Hepatitis B 2nddose + Hib 1stdose

(DPT + Hib can be given as a combined vaccine)

10-12 weeks OPV2 + DPT2 + Hib 2nddose14-16 weeks OPV3 + DPT3 + Hib 3rddose

(DPT+ Hib can be given as combined vaccines)

6-9 months Hepatitis B 3rddose

9 mon Measles vaccines15-18 months MMR vaccine,1stbooster of OPV + DPT

Booster of Hib vaccine, Varicella vaccine

2 yrs Typhoid vaccine & repeat every 3-5 years

Hepatitis A vaccine followed by 2nd

dose at 6-12 monthsfollowing 1stdose

4-6 years 2ndbooster of OPV + DPT

10 years Tetanus Toxoid

16 years Tetanus Toxoid


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DIETARY HISTORY

Calorie requirement for a child 1-10 kg 100 Kcal/ kg/day

11-20 kg 50 Kcal/ kg/day

> 20 kg

20 Kcal/ kg/day Protein requirement for a child

1.5 gram / kg / day

Simple formula Till one year age 1000 K.cal

Add 100 K.cal every year


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Cereals Protein Calories

1 cup of rice 2gms 100 cals

1 chappatti 2gms 50 cals

Pulses

1 cup of cooked dal 10gms 300 cals

Milk / 100 ml

Human mil 1.1gms 65 cal

Cows milk 3.3gms 67 cal

Fats

Ghee

1 tsp - 45 calButter 100 gms - 730 cal

Non veg

1 egg 6gms 60-70 cals

Fish 100 grams 20gms 100 cals

Mutton 100 grams 22gms 118 cals

CALORIFIC VALUES OF COMMONLY

USED FOOD STUFFS


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FAMILY HISTORY

Age of parent at marriage

H/o Consanguinity

Number of siblings Abortions or infant deaths

History of contact

Nuclear or joint family H/o Mental retardation, diabetes mellitus


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SOCIO ECONOMIC HISTORY

Number of persons living Occupation

Education

Housing conditions Type of water for drinking, cooking

Income

Per capita income = Total income of family / No. offamily members


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Kuppuswami

Scale for SES


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ALLERGIC HISTORY

Allergy to drugs

Allergy to food items like

Egg

Milk

Meat


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CONTACT HISTORY

Any history of contact with disease like

Measles

Whooping cough

Tuberculosis


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Thank you

Documents

Historytaking in pediatrics