Professional Documents
Culture Documents
PEDIATRIC HISTORY
General Data
This is a case of ___________________, ________ months/years old, Male/Female, Filipino, ___________ in religion, born
on _____________________, born in _____________________. Presently residing at ________________ , was admitted for the
______ time in this institution on _____________________ at around ______________ in the morning/afternoon/evening.
Review of System
Skin: ( ) jaundice, ( ) pallor, ( ) erythema, ( ) wound lesions
HEENT ( ) headache ( ) dizziness ( ) lightheadedness ( ) Eye redness ( )Tearing ( ) Ear pain ( ) vertigo ( )Nasal
discharge ( ) Nosebleeds
Neck ( ) Swollen glands ( ) stiffness of neck
CNS: ( ) loss of consciousness, ( ) seizure, ( ) headache
Cardiovascular: ( ) chest pain, ( ) palpitation, ( ) easy fatigability
Chest and Lung: ( ) difficulty of breathing, ( ) cough, ( ) colds, ( ) hemoptysis
GIT: ( ) anorexia, ( ) nausea, ( ) vomiting, ( ) diarrhea, ( ) constipation, ( ) hematomesis, ( ) melana
GUT: ( ) dysuria, ( ) polyuria, ( ) oliguria, ( ) anuria, ( ) hematuria
Hema: ( ) bleeding tendencies, ( ) bleeding manifestation
M/S: ( ) limitation of movement, ( ) pain on movement
Birth History
After ____ hours of labor, which started on _____ in the morning/afternoon/evening to _______ in the
morning/afternoon/evening, the patient was born via Normal Spontaneous Vaginal Delivery/Cesarian Section (if CS, secondary to
______) attended at __________________ by traditional hilot/midwife/nurse/obstetrician with ________________ presentation.
No cord coiling, amniotic fluid was clear/thinly stained meconium, with/no spontaneous respiration, with poor/good cry, in/not in
cardio-respiratory distress, with a body weight of ____ kg/lb. Routine new born screening was done/not done and within the normal
limits. The mothers blood type is ____. After _____ hospital days, the patient was discharged.
Neonatal History
The patient has/ no history of neonatal jaundice at ___ day, had/had no history of neonatal cyanosis at _____ day was
noted. Meconium was passed out during/within 24 hours of life.
Nutritional History
The patient was/not exclusively breastfed/bottle-fed since birth then shifted to formula milk at ___ months old with a
delusion of ___:___. Patient had not/been taking vitamins of with a dose of ______. Presently the patient is fond of eating
________________.
Growth and Development
New Born: () Tonic neck reflex
() Pelvic high when supine
() Fisted hands, complete head lag
() Startle reflex
2 Year: () Jumps
() Builds tower of six cubes
Immunization History
() BCG () Measles () Hep. B () MMR
() DPT () Rotavirus () OPV/ IPV () Hib B
Family History
() Asthma () Heart disease
() Allergy () Cancer
() PTB () Thyroid disease
() Hypertension () Diabetes Mellitus
Environmental History
Patient lives with ___ other household members in a non/semi congested neighbourhood. Drinking water is from water
refilling station/faucet that is boiled for ___ minutes before consumption. Garbage is/not collected. There is/no standing water in
the immediate surroundings.
Physical Examination
General Survey
The patient is awake/asleep, conscious and coherent to time and place. Not/In cardio-respiratory with the following vital
signs of:
BP=___mmHg CR=___bpm RR=___cpm Temperature: ___0C
Skin: Brown/White in complexion, () jaundice, () cyanosis, () rash, warm/cold to touch, good/poor skin turgor
HEENT: normocephalic/microcephalic/macrocephalic, () palpable head mass, flat/bulging/open/close anterior fontanel,
flat/bulging/open/close posterior fontanel, pink/pale palpebral conjunctiva, an/icteric sclera, with/without alar
flaring, with/without nasal discharge, with well formed pinna, wet/dry oral mucosa, with/no cervico
lymphadenopathy
C/L: a/symmetrical chest expansion, no/with retractions noted, clear breath sound, () crackles, () wheezes
th
CV: a/dynamic precordium, PMI is located at/not 4 ICS LMCL, regular/irregular rhythm, with/without murmur
Abdomen: flat/globular/distended, with/without visible veins, normoactive/hypoactive/hyperactive bowel sound, soft/firm
abdomen, with/without tenderness noted at _____________, liver is palpable ___cm below the right subcostal
margin, ___ liver span
Extremities: with/no gross deformities, pink/blue nailbeds, capillary refill of ___ sec, equal peripheral pulses
Neurological Examination:
CN I =
CN II =
CN III, IV, VI =
CN V =
CN VII =
CN VIII =
CN IX, X =
CN XI =
CN XII =