Pediatrics History Taking (My Protocol)
Pediatrics History Taking (My Protocol)
Pediatrics History Taking (My Protocol)
(MY PROTOCOL)
I. PATIENTS PROFILE
II. PRESENTING COMPLAINTS
III. HISTORY OF PRESENT ILLNESS
I. PATIENTS PROFILE
1) Name
2) Age (Date of Birth)
3) Sex
4) Address of parents
5) Date of admission
3) Systemic inquiry
a) General (weight loss , appetite)
b) CVS (shortness of breath on exertion , shortness of breath and sweaty on
feeding, cyanotic spells, squatting, fainting or syncope, cyanosis, edema, chest
pain/palpitations)
c) Respiratory system (sore throat, earache, cough, wheeze, frequent chest
infections, history of aspiration, hemoptysis)
d) Gastrointestinal system (abdominal pain, vomiting, jaundice,
diarrhea/constipation, blood in stools)
e) CNS (fits, syncope/dizziness, headache, visual problems, numbness/unpleasant
sensations, weakness/frequent falls, incontinence)
f) Genitourinary system (stream, dysuria, frequency, nocturia/enuresis,
incontinence, hematuria)
g) Rheumatological system (limp, joint swelling, hair loss, skin rash, dry
mouth/mouth ulcers, dry or sore eyes, cold extremities)
POSTNATAL HISTORY
VI. IMMUNIZATION
(check vaccination card * )
1) Significant illness in the past (esp. diarrhea, respiratory infections, fevers, fits, jaundice)
2) History of similar complaints in the past
X. DRUG HISTORY