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2. Drugs taken – alcoholic/smoking mother?

Paediatric Clerkship  Pregnancy meds – folic acid, iron, antiemetics,


Pt ID (AGE-O-ADD-NI) antacids
 Name – include RN  Teratogenic drugs – ACE inhibitors, sodium
 Age – include DOB valproate, methotrexate, retinoids, trimethoprim
 Address – include reachability of healthcare services  OTC drugs – ensure nothing is unsafe/teratogenic
 DOA – Private clinic/KK/ER/Transfer/Referral 3. Antenatal check-up – compliance, any informed problems?
 Informant – Relation to patient, reliability
o Fetal health
1. IUGR
CC (Complaint – Duration) 2. Poly-/Oligohydramnios
Max 3 – in chronological order 3. Premature rupture of membranes (PROM)
4. Umbilical cord prol apse
HOPI  IP
 Relevant hx (U/L) – risk factors, complications from past/concomitant o Delivery
illness(es) 1. Method - use of forceps, anesthesia?
 Premorbid status 2. Duration
 Symptoms & corresponding exploration in chronological order (P/W) – rule  Failure to progress
out Ddx 3. Complication
 Review of systems (O/W) – rule out Ddx (refer Appendix 2 below)  Birth asphyxia
 List out Pdx & Ddx o Placental insufficiency
o Premature separation of placenta
Past Medical and Surgical History o Umbilical cord compression
1st hospitalization? o Knotting of umbilical cord around infant’s
NKMI? neck

Medical/Surgical - Who - Current Tx & Rx:  PP/Neonatal period


- Where - Compliance o State after birth
- When – how long? (i) Drug: 1. APGAR score:
(ii) Follow up: a. Poor/active cry
b. Pink/cyanosed
Paediatric History c. Activity
A. Birth History 2. Birth injury @ resuscitation given
FT?, SVD?, bw, Where/who deliver 3. Jaundice
4. Illness & hospitalization
 AP
o Maternal health B. Developmental history – refer Appendix 1 below
1. Illness during pregnancy
a. GDM
b. PIH
c. Bleeding
d. Infectious illnesses – fever?
e. Trauma
f. Asthma
g. Hyperemesis gravidarum
C. Immunization History o Sewage
- Up to date? Last immunization received? o Household waste disposal
- Status: Complete/incomplete/none o Ventilation
 Parents
Newborn – BCG, Hep B o Education level
1 month – Hep B o Occupation
2 month – DTaP, Hib, IPV o Coping mechanism in caring for children
3 month – DTaP, Hib, IPV o Smoking/alcohol habits
5 month – DTaP, Hib, IPV  Household economy
6 month – Hep B o Monthly household income
9 month – MMR, JE (S’wak only) o Financial problems (Tx)?
12 months – MMR  School/nursery
18 months – DTaP, Hib, IPV o Overcrowding
21 months – JE (S’wak only) o Sick contact
Standard 1 – MR, DT o General Hygiene
Form 1 – HPV (girls only) o Performance & social interaction
Form 3 – Tetanus
Drug & Diet History
D. Feeding History  Drug
- EBF – duration (each session), frequency/day o Modern medicine
- Bottle feeding  Prescribed
o When start  OTC
o Frequency/day o Traditional medicine
o Ounces each bottle  Current diet
o If discontinue – why?  Allergy
- Weaning – When, what solid food, any problems? o Drug
o Food
Family History
- Family Pedigree – 1st marriage? Summary
- Include: - Patient ID
 3 generations - Chief complaint
 Similar illness, common illness & Health status - History suggestive of diagnosis
 Consanguineous marriage o Positive
o Negative
Social & Personal History - History suggestive of complication(s)
 Living condition o Positive
o Living with parents/guardian o Negative
o Taken care of by?
o House type & amenities
 Rented?
o Locality
o Pets
o General hygiene
 Amenities
o Water supply
o Electricity
Appendix 1: Developmental History

Gross motor (median ages) Vision & Fine motor Hearing, Speech, Language Social, emotional & behavioural development
- Limbs flexed, symmetrical posture - Follow moving object/face by turning - Startle to loud noises - Smiles responsively (6 wks)
(newborn) head (6 wks) (newborn)
- Puts food in mouth (6 – 8 mo)
- Marked head lag on pulling up - Reaches out for toys (4 mo) - Vocalizes alone/when spoken to,
(newborn) coos & laughs (newborn) - Waves bye-bye, plays peek-a-boo
- Palmar grasp (4 – 6 mo) (10 – 12 mo)
- Raises head to 45 degree in prone (6 – - Turns to soft sounds out of sight (7
8 mo) - Transfer toys frm one hand to another mo) - Drinks frm a cup with 2 hands (12
(7 mo) mo)
- Sitting - Sounds used indiscriminately (7 mo)
- Mature pincer grip (10 mo) - Holds spoon & gets food safely into
 w/o round back (6 mo) - Sounds used discriminately to mouth (18 mo)
 straight back (8 mo) - Stacking blocks (14 mo – 4 yrs) parents (10 mo)
- Symbolic play (18 – 24 mo)
- Crawling (8 – 9 mo)  Tower 3 @ 4 = 18 mo - Speaking single words
(12 mo) - Dressing (2 yrs)
- Cruises around furniture (10 mo)  Tower 6 = 2 yrs  2 – 3 words other than
‘dada’ or ‘mama’ - Parallel play. Interactive play
- Walking by 10 –14 months  Tower 8 @ train 4 = 2 ½ yrs evolving. Takes turn. (2.5 – 3 yrs)
- 6 – 10 words. Shows 2 parts of the
 Walk unsteadily, broad gait,  Bridge (frm model) = 3 yrs body (18 mo) - Self-feeding using cutlery (3 yrs)
hands apart (12 mo)
 Steps (after demo) = 4 yrs - Making word combinations (2 yrs) - Playing cooperatively in groups
- Walk steadily (15 mo) (3 yrs)
- Makes marks with a crayon (16 – 18 - Making clear, simple sentences,
- Climbing (2.5 yrs) mo) being interested in books & stories - Being toilet-trained (3.5 yrs)
(3 yrs)
- Throwing and kicking a ball (2 yrs) - Drawing  Talks constantly in 3 – 4
 Line (2 yrs) word sentences - Playing team games (7 yrs)
- Pedaling a tricycle (3 yrs)  Circle (3 yrs)
 Cross (3.5 yrs) - Making conversation clear to
- Hopping (4 yrs)  Square (4 yrs) others (3 @ 4 yrs)
 Triangle (5 yrs)
- Skipping (6 yrs) - Reading (5 - 6 yrs)
- Completing simple form boards (2 yrs)

- Threading beads (3.5 yrs)

- Cutting a piece of paper (3 yrs)

- Copying geometric shapes (4 yrs)

- Tying shoelaces (5 yrs)

- Printing legibly (6 yrs)


Appendix 2: Review of Systems 8. Abdominal pain/ swelling
9. Jaundice
10. Stool colour
 Constitutional
11. Swallowing difficulty
1. Weight loss @poor weight gain
12. Colic – repeated bouts of excessive crying >3hrs/d, >3d/wk
2. Change in appetite
13. Appetite
3. Fever
4. Change in activity level
 Nervous system

 Cardiovascular system 1. Headache


2. Trauma
1. Sweating/colour changes with feeding 3. Loss of consciousness
2. Cyanosis – blueness around the mouth/lips 4. Seizure activity
3. Slow feeding (>20 min to take a bottle) 5. Developmental delays – motor, verbal
4. Chest pain 6. Weakness of muscles @paralysis
a. Onset – On exertion, at rest 7. Abnormal movement/fits
5. Rapid/irregular heart beat 8. Blurred vision
6. Rapid breathing @laboured breathing 9. Giddiness @syncope
a. Onset – On exertion, lying flat (orthopnoea), 10. Numbness @paresthesia
b. Nature – Diurnal variation (@night)  Paroxysmal nocturnal
dyspnea  Musculoskeletal system
7. Syncopal attacks @fainting – with activity?
8. Dizziness – with activity? 1. Muscle pain @tenderness
9. Fatigue 2. Muscle wasting @weakness
10. Cough 3. Joint pain @tenderness
11. Wheezing 4. Joint swelling @stiffness
12. Ankle swelling 5. Bone pain @deformity
13. Recent h/o murmur 6. Dry eyes/ mouth
7. Trauma
 Respiratory system 8. Scoliosis

1. Rapid breathing  Hematological system


2. Cough
3. Wheezing @stridor 1. Easy bruising
4. Chest pain 2. Tendency to bleed
5. Runny nose @obstruction 3. Swollen lymph nodes
6. Hoarseness of voice 4. Pallor
5. Frequent infection
 Gastrointestinal system 6. Bone pain

1. Nausea  Allergy
2. Vomiting  bloody/bilious 1. Urticaria
3. Diarrhea 2. Hay fever
4. Constipation 3. Allergic rhinitis
5. Hematemesis 4. Asthma
6. Hematochezia/malena 5. Eczema
7. Describe stooling habits – altered bowel habits? 6. Drug reactions
 Integumentary
 Genitourinary system
1. Recent rashes
1. Problems with micturition 2. Skin discoloration
a. Dysuria a. Bruising
b. Frequency b. Petechiae
c. Incontinence/ Dribbling 3. Nodules/ tumours on the skin
d. Urgency 4. Birthmarks
e. Reduced flow/ Hesitancy
f. Urinary retention
 ENT
2. Alteration in urine
a. Amount 1. Change in vision
i. Polyuria/ nocturia 2. Change in hearing
ii. Oliguria 3. Photo-/Phonophobia
iii. Anuria 4. Runny nose
b. Appearance 5. Ear pain
i. Cloudy 6. Sore throat
ii. Frothy 7. Neck pain
iii. Smoky brown 8. Speech problems
c. Colour change 9. Mouth sores
i. Tea-coloured
ii. Red
 Psychiatric
3. Hematuria
4. Abdominal pain 1. Clingy
5. Edema @puffiness of face 2. Fussy
6. Itchiness of skin 3. Decreased energy level
7. Sexual activity, LMP, STI exposure 4. Disciplinary problem @home/school
5. Abnormal interaction with peers/ family
6. Substance abuse – alcohol, cigarettes, drugs
 Endocrine system

1. Polyuria  Reproductive system @pubertal


2. Polydipsia 1. Secondary sexual characteristics
3. Heat/cold intolerance 2. Menses/menstrual problems
4. Growth pattern 3. Pregnancies
4. Sexual activity