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Year
3 medical students King Fahad Medical City on December 17, 2013 by Professor
Omar Hasan Kasule Sr.
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1.0
DEMOGRAPHIC INFO
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Names
of child and parent(s)
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Age
and date of birth
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Residential
address
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Parental
occupation
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Child’s
school etc
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2.0
HISTORY OF
PRESENTING COMPLAINT
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Onset,
course, location, severity, time of day, duration, diurnal variation,
character, aggravating factors (food, cough etc ), relieving factors
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Associated
symptoms,
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What
does the parent think is going on?
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Treatments
already given
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How
the family is affected
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Missing
school
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Associated
behavioral problems
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3.0
PAST MEDICAL /
SURGICAL HISTORY
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Prenatal
period: prenatal care for the mother (where and how much); alcohol,
drugs, and cigarettes by the mother;
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Birth:
mode of delivery (Caserean or vaginal), delivery complications, APGAR score
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Neonatal
period: respiratory problems, feeding problems, jaundice
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Chronic
illnesses: asthma, respiratory infections
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Childhood
infections; eg measles varicella
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Hospitalizations
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Surgeries
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4.0
NUTRITIONAL HISTORY
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Breast
feeding (how often, baby satisfied?, crying, urine output), time of weaning
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Formula:
brand name, how prepared, how stored,
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Solid
food: types and amounts, ?junk food
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Milk
and juices
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5.0
DEVELOPMENTAL
HISTORY
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Gross
motor & Fine motor
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Vision
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Social
and play
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Speech
and hearing
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6.0
ALLERGY HISTORY
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Reactions
to medications: type and drug
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Distinguish
true allergy vs medication effects (eg vomiting)
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Food
allergies
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Environmental
allergies
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7.0
MEDICATION HISTORY
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List
of current medications doses and why
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List
of chronic medications
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8.0
IMMUNIZATION
HISTORY
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Record of the whole immunization schedule
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Reactions to immunization: swelling,
tenderness, fever
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Treatment of reaction
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9.
FAMILY HISTORY
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Parents:
age, height, weight, health status, consanguinity, region of origin
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Siblings:
names, nicknames, age, height, weight, health status
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Significant
problems maternal & paternal
sides: arthritis, DM, HT, renal disease, anemia, headache, TB
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10.
SOCIAL HISTORY
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Type of
housing, location (city vs rural), how many people in house
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Parents:
education, occupation, income, religion and culture, smoking
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Care
for children: baby sitter, grandparents, other relatives,
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Discipline
(may relate to child abuse)
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Health
insurance
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Contact
with animals
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11.
REVIEW OF SYSTEMS (If not covered in presenting complaints and PMH)
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Skin:
skin rash,
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CVS:
dypnea, cyanosis, sweating on feeding
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Hematological:
pallor, jaundice, bone pain, bruises, epsitaxis
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RES:
dypnea, runny nose, cough, hemoptysis, wheeze/stridor, sore throat, ear ache,
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GIT:
Vomiting, abd pain, diarhoea / constipation, Bowel habits, feeding, weight
loss
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Urinary
tract: dysuria, enuresis, frequency. Nocturia, hematuria, incontinence
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CNS:
irritability, drowsiness, abnormal movements, headache, numbness,
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Sleeping:
night walking, crying, sleep walking, sleep talking, nightmares,
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Musculoskeletal:
joint swelling, joint pain, skin rash
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Behavior:
temper tantrums, sibling rivalry, mealtime behavior, bedtime behavior,
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12.
RISK FACTORS
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13.1Pyrexia
of undetermined origin (PUO)
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Infections
(bacterial, viral, parasitic)
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Drug
reactions
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Allergy
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Dehydration
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Neoplasms
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Factitious
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12.2.
Failure to thrive (height for age. Weight for age, weight for height,
birth weight, milestones)
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Familial
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Delayed
but normal growth
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Inadequate
caloric intake (no food, poor appetite, wrong food, psychosocial eg maternal
depression, family disruption)
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Renal
disease (infection, renal failure)
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Cardiovascular: congenital heart disease, endocarditis, myocarditis
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GIT:
cleft lip / palate. Esophageal compression, gastro-intestinal reflux, hernia,
pyloric stenosis, celiac disease, hepato-pancreatic disorders, endocrine
disorders (thyroid, GH deficiency, adrenal insufficiency, diabetes)
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Musculoskeletal:
rickets due to Vit D deficiency,
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Chronic
infections: TB,
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Metabolic
disorders (
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Chronic
anemia: thalassemia, sickle cell
disease,
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Respiratory:
Chronic lung disease: asthma, infections, airway obstruction
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12.3.
Weight loss
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Infections
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Eating
disorders
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Depression
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Thyrotoxicosis
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Renal
failure
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Malignancy
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Inflammatory
bowel disease
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Celiac
disease
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tbc...