- Age/Date of Birth
- Informant ( Reliability)
- Parent’s name, age, address, education, religion
Chief Complaints (CC):
- Symptoms X Duration in Chronological order
History of Presenting Illness (HPI):
- Symptoms: Location, quality, quantity, aggravating and alleviating factors
- Time course: Onset, duration, frequency, change over time
- Rx/Intervention: Medications, medical help sought, other actions taken
- Etiology and risk factors
- Contact history: Exposures, ill contacts, travel
Review of Systems (ROS):
- General—fever, activity, growth
- Head—trauma, size, shape
- Eyes—erythema, drainage, acuity, tearing, trauma
- Ears—infection, drainage, hearing
- Nose—drainage, congestion, sneezing, bleeding, frequent colds
- Mouth—eruption/condition of teeth, lesions, infection, odor
- Throat—sore, tonsils, recurrent strep pharyngitis
- Neck—stiff, lumps, tenderness
- Respiratory—cough, wheeze, chest pain, pneumonia, retractions, apnea, stridor
- Cardiovascular—murmur, exercise intolerance, diaphoresis, syncope
- Gastrointestinal—appetite, constipation, diarrhea, poor suck, swallow, abdominal pain, jaundice, vomiting, change in bowel movements, blood, food intolerances
- GU—urine output, stream, urgency, frequency, discharge, blood, fussy during menstruation, sexually active
- Endocrine—polyuria/polydipsia/polyphagia, puberty, thyroid, growth/stature
- Musculoskeletal—pain, swelling, redness, warmth, movement, trauma
- Neurologic—headache, dizziness, convulsions, visual changes, loss of consciousness, gait, coordination, handedness
- Skin—bruises, rash, itching, hair loss, color (cyanosis)
History of Past Illness:
- Date and Interventions for: Exanthems, Pertussiss, Respiratory tract infections, Gastrointestinal infections, Previous similar episodes, Any significant disease, accidents or injuries, Foreign body
- Pregnancy (Antenatal): Gravida/Para status, Maternal age, Duration, Exposures (medications, alcohol, tobacco, drugs, infections, radiation), Complications (Bleeding, Diabetes, Hypertension), Problems with previous pregnancies, Occurred on contraception? Planned?
- Labor and Delivery (Natal): Length of labor, Rupture of membrane, Fetal movement, Medications, Presentation, Mode of delivery, Assistance (Forceps, vacuum), Complications, APGARs, Immediate breathe/cry, Oxygen requirement, Intubation and duration
- Neonatal (Postnatal): Birth height and weight, Abnormalities, Injuries, Length of hospital stay, Complications (Respiratory Distress Syndrome, Cyanosis, Anemia, Jaundice, Seizures, Anomalies, Infections), Behavior
- Assess each of the 4 areas individually in order: Gross motor, Fine motor, Language, Personal social
- Ask the milestone which you expect the child to achieve at that age
- If the child has acquired these functions, the development can be considered as normal. State as follows: The development of this __ months old child matches the chronological age in all 4 spheres of development.
- If the child has not acquired the desired function, ask for a function that the child would have achieved by an earlier age, in that particular sphere of development. State as follows: The development of this __ months old child in the __ area corresponds to a chronological age of between __ to __ months.
- Try to find out etiology through perinatal, family or social history, if there is developmental delay
- relatives, ages, health problems, deaths (age/cause), miscarriages/stillbirths/deaths of infants or children, pedigree chart upto 2nd degree (Upto 3rd degree if genetic disease suspected)
- Parent’s education and occupation, living arrangements, pets, water supply, lead exposure (old house, paint), Smoke exposure, religion, finances, family dynamics, risk taking behaviors, school/daycare, other caregivers
- When was the 1st feed given?
- Whether baby received any prelacteal feeds?
- How many times breast-feed is given in last 24 hours?
- How many night feeds were given?
- Does the child receive any other food or drink in addition to breastfeeds? If yes which food and drink?
- If animal milk/formula milk: how many times in last 24 hours? Dilution?
- What is being used to feed the child if baby is receiving feed other than breastfeeds: cup/spoon/bottle?
- How feeding bottle/cup is prepared: washing? Boiling?
- How many times baby is passing urine in 24 hours?
- What is the color of urine?
- Ask mother if she has any pain during breastfeeding?
- up to date, reactions
- past (antibiotics, especially), present, reactions