MD-PEDc-008-01

ILOCOS TRAINING AND REGIONAL MEDICAL CENTER

DEPARTMENT OF PEDIATRICS
PEDIATRIC CLINICAL HISTORY
General Data
This is the case of _____________________________________, ___months/year old, M/F, _________ (Religion), born on
______________ in ____________________________________ presently residing at ______________________________________,
admitted for the ___________time in this institution on _____________.

Informant: Percent Reliability:

Relationship of informant to patient:

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:

PAST PERSONAL & MEDICAL HISTORY:

I. Birth History:
a. Prenatal History:
The mother was ___years old, G__P__(_____), cognizant of pregnancy at ___ weeks AOG due to amenorrhea from a
previously regular/irregular menstrual cycle, confirmed by a pregnancy test done at home/clinic. Prenatal care was
instituted at ______weeks AOG by ____________. She had a total of ____prenatal checkups done regularly/irregularly.
UTZ was done at ______weeks AOG revealing _____________________________________________. There is/are history
of exposure(s) to VED/smoking/alcohol/radiation.
b. Natal History:
Patient was born term/preterm via NSVD/LSCS at _______________by_____________. BW was _____kg and BL was
_____cm. Patient had pink/cyanotic body with good/weak/no cry and limp/active limb movements upon birth.
With/without resuscitative measures done. AS:_______ BS:__________
c. Neonatal History:
Patient was breastfed/bottlefed with good/poor suck, hospital stay ______. Umbilical stump fell off after ____days/weeks
with/without signs of infection. Newborn screening results _________________________.

II. Feeding History:

Patient was breastfed/bottlefed per demand/schedule up to ______ months/years old. Complementary milk was given at
___months/years old with _________ dilution consuming about _____ml per feeding with a frequency of about _____
Semi solid foods were introduced at _______ months. At present, sample diet includes:
BREAKFAST
LUNCH
DINNER
SNACK
Multivitamins ______________________ were given to the patient at ____ old. At present, patient is given with
________________________________________________.
III. Growth and Development:
Physical Growth:
BW: Present weight:
BL: Present height:
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Developmental milestone
Age Gross motor Fine motor Language Personal/social
1 month Raises head slightly, hands fisted Crying
2 months Head control 45 degrees Eye follow object to Crying Regards face
Holds head in midline midline
Hands no longer fisted
3 months Head control 90 degrees Hands together in Orients to voice Regards hands
Pull to sit, No head lag midline
4 months Rolls over Reaches a grasp Orients to voice Regards hands
5 months Good head control Play with rattle in hand
6 months Sits without support Can chew Monosyllabic babble Enjoy looking around the
environment
7 months Bounces, crawls Indicates likes and dislikes
8 months Leans Bangs 2 cubes Dada, Mama indiscriminately
9 months Creeps One word other than mama, dada Close permanence
10 months Pull self to stand One word other than dada, mama Shy with strangers
11 months Walks holding on Pincer grasp
12 months Stands alone Egocentric pretend play
15 Walks well alone Makes line with crayon 4 – 6 words other than dada, mama Pats pictures
18 months Runs stiffly, seats self in child’s Imitates vertical Names picture, 10 words, identifies Buttons up, tells “tail tales”,
chair, walks upstairs with one strokes/scribing, builds 1 or more body parts goes to toilet alone
hand held tower cubes, dumps
pellet from bottle
2 years Walks well 2 step commands Dresses self completely

3 years Rides tricycle Imitates cross Knows age and sex Sense of humor
4 years Hops on one foot, climbs well, Copies square, bridge, Knows color, counts 4 pennies, says
walks downstairs, alternating feet draws man with 3 parts, song and poem from memory
names longer of two
lines
5 years Skips both feet, heel to toe walk, Copies triangle, writes Counts 10 pennies, prints first
jumps over low obstacles alphabet, ties shoes, name, ask what a word means
spread with knife
6 years Backward heel to toe walk Draws a complete peron Adds and subtracts, distinguishes
with clothing, can write between left and right
fairly well
8 years Complex pattern movement Awkward and self Tells time
conscious
Developmetal milestone are at _______ with age
Speech development: performance in preschool and/or school:

Social development:
Patients sleeps ______ in the evening and wajes up at ______ in the morning. Non/toilet trained, interacts with family and
peers with/without discipline problems.

IV. Immunization: indicate in age in months/years given

Vaccine 1st dose 2nd dose 3rd dose Booster Place Reaction
BCG
DPT
OPV
Hepatits B
Measles
MMR
HIB
Influenza
Pneumococcal
Rotavirus
Meningococcal
Hepatitis A
Varicella
Typhoid
Others
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V. Past Medical History

a. Past hospitalization (where/when/why)

b. Childhood illnesses

c. Allergies

d. Current medications

VI. Family History

Both parents are well. There is family history of ( ) bronchial asthma, ( ) hypertension, ( ) DM, ( ) arthritis, ( ) CVD, ( ) CAD, (
) malignancy (specify ___________________), ( ) twinning, Others:

VII. Social and environmental history

Father is ____y/o, currently working as a ____________________, graduate of _______________.
Mother is ____ y/o currently working as a ___________________, graduate of _______________. Primary caregiver is the
______________. Patient is the __________child of _________siblings.

Family member with the same illness?

Patient lives along a non/congested neighborhood in a ________________ house with _____ rooms with _____ occupants.
Source of water for domestic purposes comes from _________________. Drinking water comes from ____________________ and
boiled/not boiled for _________ minutes. They have ______ pets, garbage is collected regularly every ______________. Toilet is
_________ type. Handwashing practices: __________

VIII. Review of Systems

General survey: ( ) weight loss, ( ) febrile episode, ( ) chills, ( ) sweats, ( ) incessant crying, ( ) irritability, ( ) poor/fair/good oral
intake, ( ) lethargy
Integumentary: ( ) cyanosis, ( ) pallor, ( ) lesions, ( ) dryness, ( ) rash, ( ) itching, ( ) moles, ( )sores, ( ) hives, ( ) pigmentation
Head and neck: ( )lesion, ( ) trauma, ( )swelling, ( ) headache, ( ) pain, ( ) stiffness
Eyes: ( ) tearing, ( ) itching, ( ) redness, ( ) discharges, ( ) pain, ( ) diplopia, ( ) dryness, ( ) infection, ( ) corrective lenses
(age appropriate)
Ears: ( ) discharges, ( ) pain, ( ) tinnitus, ( ) vertigo, ( ) hearing loss
Nose: ( ) dryness ( ) congestion, ( ) colds, ( ) sneezing, ( ) pain, ( ) obstruction, ( ) smell, ( ) bleeding
Mouth and throat: ( ) soreness, ( ) pain, ( ) infection, ( ) ulcers, ( ) hoarseness, ( ) dryness, ( ) gum bleeding, ( ) dental
caries, ( ) tongue lesion, ( ) swallowing problems
Breast (for adolescent and breast complaint): ( ) discharges, ( ) lump, ( ) bledding, ( ) infection
Respiratory: ( ) cough (dry/productive), ( ) sputum (white/yellow/green), ( ) pain, ( ) dyspnea, ( ) hemoptysis, ( ) cyanosis, ( )
TB/PPKI
Cardiovascular: ( ) edema, ( ) cyanosis, ( ) palpitations, ( ) murmur, ( ) known CHD, ( ) rheumatic fever/RHD
Gastrointestinal: ( ) good/poor appetite, ( ) anorexia, ( ) abdominal pain, ( ) vomiting, ( ) nausea, ( ) diarrhea, ( ) constipation, ( )
flatulence, ( ) melena, ( ) hematochezia, ( ) change in bowel habits, ( ) hernia, ( ) use of laxatives or antacids, ( ) jaundice, ( )
hepatitis
Urinary and Renal: ( ) dysuria, ( ) hematuria, ( ) nocturia, ( ) incontinence, ( ) frequency, ( ) stones, ( ) infections
Genital: ( ) pain, ( ) swellimg, ( ) discharges, ( ) tenderness, ( ) itch
Musculoskeletal: ( ) deformities, ( ) pain, ( ) swelling, ( ) tenderness, ( ) cramps, ( ) weakness, ( ) trauma, ( ) sprains, ( ) fractures,
( ) stiffness, ( ) backache
Endocrine and Metabolic: ( ) polydipsia, ( ) polyphagia, ( ) hair change, ( ) weight change, ( ) temperature intolerance
Hematologic: ( ) anemia, ( ) bleeding, ( ) bruising, ( ) transfusions, ( ) malignancy
Nervous System: ( ) syncope, ( ) dizziness, ( ) seizures, ( ) convulsions, ( ) tremors, ( ) coordination problems, ( )sensory
disturbances, ( ) motor problems, ( ) memory problems

IX. Physical Examination

General appearance:

Vital signs
BP: / CR: RR: temperature:

Anthropometric Measurements:
Weight: ___________kg (________SD)
Height: ___________cm (________SD)
2
BMI: __________ kg/m (________SD)
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Skin: ( ) pallor, ( ) jaundice, ____________to touch, ___________skin turgor, ( ) rashes, ( ) petechiae, ( ) pigmentations

HEENT
Head: ( ) scars, ( ) lesions, ( ) gross deformities, ( )_________ hair distribution, non/sunken fontanels, ( ) tenderness
Eyes: non/sunken eyeballs, ( ) periorbital edema, an/icteric sclera, pale/pink palpebral conjunctiva, ____________corneal
firm, pupils ERTL, ( )discharges
Ears: abnormally set ears, ( ) discharges, ( ) impacted cerumen, _________ tympanic membrane
Nose: ( ) discharges, ( ) congestion, ( ) alar flaring
Mouth and pharynx: ______ lips, ______ buccal mucosa, ( ) circumoral cyanosis, ( ) TP wall congestion, ( ) ulcers, ( )
exudates, ( ) enanthems, ( ) pigmentation, ( ) dental caries
Neck: supraclavicular and suprasternal retractions, ( ) neck vein engorgement, ( ) cervical LAD, ( ) tenderness
Chest and Lungs: ______________ chest expansion, ( ) lagging, ( ) retractions, __________ breath sounds, ( ) crackles, ( )
wheeze, ( ) rhonchi
Heart: A/dynamic precordium, PMI at ______ ICS LMCL, _________ rate and _________ rythym, ( ) thrills, ( ) murmurs
Abdomen: flat/globular/scaphoid/flabby, non/distended, hypo/normo/hyperactive bowel sounds, tympanitic,dull, soft/rigid. ( )
tenderness, ( ) masses, ( ) organomegaly, liver span ____cm
Genitalia: grossly ________, SMR _______
Extremities: no gross deformities, __________ peripheral pulses, _______capillary refill time
Neurologic Exams
Cerebral function:
Cerebellum function: ( ) tremors, ( ) nystagmus, ( ) ataxis
Carnial nerve function test:
CN I: ( ) smell
CN II: ( ) see
CN II and III: pupillary light reflex ____________
CN III, IV and VI: extraocular muscle movements
CN V: ( ) corneal reflex, ( ) chew
CN VII: a/symmetric nasolabial folds on smiling
CN VIII: ( ) sense of hearing
CN IX and X: uvula at mdline/deviated to R/L, ( ) gag reflex
CN XI: _________ to shrug shoulder, ________ to move head from side to side
CN XII: _________ to protrude tongue, ( ) deviation, ( ) fasciculations

Sensory: Motor: Reflexes

Babinski:
Ankle clonus:
Kernig’s sign:
Brudzinski sign:

Admitting diagnosis :

Therapeutics

Monitor VS q _____ and record

Strict I and O q shift and record
Refer accordingly

Admitting resident: