PEDIATRICS HISTORY TAKING

(MY PROTOCOL)

I. PATIENTS PROFILE
II. PRESENTING COMPLAINTS
III. HISTORY OF PRESENT ILLNESS

IV. BIRTH HISTORY

V. FEEDING HISTORY
VI. IMMUNIZATION
VII. DEVELOPMENTAL HISTORY

VIII. PAST HISTORY

IX. PERSONAL HISTORY
X. DRUG HISTORY
XI. FAMILY HISTORY
XII. SOCIO-ECONOMIC HISTORY

I. PATIENTS PROFILE

1) Name
2) Age (Date of Birth)
3) Sex
4) Address of parents
5) Date of admission

II. PRESENTING COMPLAINTS

(Use parents own words + chronological order)

III. HISTORY OF PRESENT ILLNESS

1) Enquire as to when patient was last entirely well?

2) Presenting complaints
a) Time (onset , duration , frequency , course)
b) Place (site)
c) Quality (character e.g. of pain , composition of vomitus)
d) Quantity (severity of pain , amount of vomitus)
e) Provocative / alleviative factors / variations (diurnal or seasonal)
f) Associated symptoms
g) Treatment if any

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)

IV. BIRTH HISTORY

(Important in neonatal, genetic or developmental case)

ANTENATAL HISTORY (H/O PREGNANCY)

1) H & N status (Health and nutritional status of mom during

pregnancy)
2) Illness during pregnancy (HTN, DM, pre-eclampsia, antepartum
haemorrhage)
3) Infections during pregnancy (rubella, UTIs, syphilis, T.B.)
4) Drugs (iron, multivitamin, other drugs with dose, duration and at
which time of gestation)
5) X-ray (h/o irradiation in 1st trimester)
6) TT (maternal vaccination against tetanus)
7) Past obstetric (problems with previous pregnancies, stillbirths,
miscarriages, birth weight of previous children, prematurity, blood
transfusions)

NATAL HISTORY (H/O DELIVERY)

1) Place of delivery (hospital/home)

2) Conducted by (dai/trained health visitor/doctor)
3) Sterilization technique for instruments
4) Gestation time (length)
5) Rupture time (time of rupture of membranes)
6) Labour time (duration)
7) Presentation and type of delivery (SVD, forceps, vacuum extraction
or C-section)
8) Sedation/analgesics during labour
9) Complications (abnormal bleeding)

POSTNATAL HISTORY

1) 1ST cry (immediately/cyanosed/apneic)

2) Basic problems (need for resuscitation, problem with respiration,
sucking/swallowing)
3) Birth weight
4) Birth injury
5) Convulsions, cyanosis, jaundice, fever, rash
6) Procedures (exchange transfusion, umbilical artery catheterization,
drugs)
 V. FEEDING HISTORY
(Significant in child < 2 years , anemic or malnourished)

1) Onset of feeding (after how many hours)

2) Type of feed
Breast-fed (duration)
Bottle-fed (at what age, composition of formula, amount, frequency, dilution)
3) Supplements (vitamin, iron)
4) Weaning (when, what, amount, frequency)
5) Current diet/change in diet during illness

VI. IMMUNIZATION
(check vaccination card * )

1) Types of Vaccinations given

2) Age at which started and by whom
3) Doses & adverse effects

VII. DEVELOPMENTAL HISTORY

1) Achieving age of various milestones

Smiling
Ability to hold neck
Sit
Crawl
Stand
Walk
Talk
Control of bladder and bowel

2) Compared with normal for this age

VIII. PAST HISTORY

1) Significant illness in the past (esp. diarrhea, respiratory infections, fevers, fits, jaundice)
2) History of similar complaints in the past

IX. PERSONAL HISTORY

1) Particular habits of child
2) Details of class, school and interest in studies
3) Any missed school attendance
4) Behavior of the child at school and relationship with other children

X. DRUG HISTORY

1) Any medications used (frequency, dose, adverse effects)

2) Allergy to any drug
3) H/o Mom drug usage ** (in neonate or breast fed baby)
XI. FAMILY HISTORY
(Important in chromosomal, hereditary, infectious diseases)

1) Age of mother and father? How long married?

2) Consanguinity ***
3) Parents health (present and past)
4) Siblings
Number
Age and sex
Illness
Any death (cause if known or symptoms of illness before death)
Stillbirths, miscarriages

5) Grand parents health (esp. if living with family)

6) Health of uncles, aunts and their children (if inherited disorder suspected)
7) DO MAKE A FAMILY TREE ***

XII. SOCIO-ECONOMIC HISTORY

1) Parents education and occupation

2) Family income
3) House (made of, persons living, size)
4) Cleanliness and general hygienic conditions
5) Source of drinking water
6) Any pets at home