Pediatric Hx Writing Flashcards
1
Q
- Onset of illness and duration
o Ask the mother when the fever started, and if how many
days) - Nature and character
o Diarrhea – color of stools, blood-streaked, mucoid etc. - Severity
- Aggravating Conditions
- Relieving Conditions
o Medications - Associated signs and symptoms
o Fever – may have cough, coryza
o Abdominal pain – vomiting or diarrhea
o Do not ask the mother “What are the associated signs and symptoms”
o Give them the list that could be associated with the dse - Problems in feeding and sleep (common)
- Medications
o Generic name (Capitalize the first letter)
o Brand name (in closing parenthesis)
o Dose (very important, compute the dose base on weight
to avoid under or overdosing)
o Response
A
HPI
2
Q
- Mothers age and OB score at the time of pregnancy
o (not at the time of admission) - Pre-natal care visits
o when she started, if regular visits? - Laboratories taken
o CBC, UA, Hep B, HIV, Group B Strep testing, Ultrasound results
o Include results and findings - Illnesses during pregnancy
o (UTI, Measles @ 1st trimester) - Drugs taken during pregnancy aside from the prenatal vitamins,
ask if the mother took prohibited drugs or drugs for abortion - Smoking
- Alcohol intake
A
Pre-natal History
3
Q
- Age of gestation
o preterm, term, full term or post term if they can’t remember the specific week - Birth rank
- Mode of delivery
o normal vaginal, caesarian, forceps - Where delivered
o hospital, home, lying in clinic - Who attended the delivery
o OB resident, private physician, midwife - Condition upon delivery (APGAR score)
o Good cry upon delivery - Birth weight
- Perinatal complications o Sick at birth or in the nursery o Jaundice or meconium staining o If preterm, the baby may stay in the nursery for a longer period of time
- Duration of stay in the hospital or lying in clinic
o Lying clinic – discharge within 24 hours
o Hospital – discharge within 2-3 days
o If the baby stayed for about a week, there might be a perinatal complication
A
Natal History
4
Q
- Feeding History
- Growth and Development
- Immunization History
- Past Medical History
A
Post Natal History
5
Q
- Type of feeding
o Purely breastfed or bottle fed with milk formula
o Mixed feeding (both bottle and breastfed)
o Duration, ask how long - Age when semi-solids were introduced
o Usually at 6 months
o Cerelac, Gerbers, mashed veggies
A
Feeding History
6
Q
- Approximate age when major development milestones
were acquired - Gross motor, fine motor, social, language
A
Growth and development
7
Q
- Past illnesses o Chicken pox o Measles - Previous hospitalizations and surgery - Food and drug allergies
A
Past Medical History
8
Q
- Ages of their parents and their work
- Brief description of their dwelling place
- Water source – especially for drinking
- Garbage disposal
A
Social History
9
Q
Focuses
Fixes/follows
Responds to sounds
Regards face
A
birth - 1 month
10
Q
Head ctrl
Coos
A
1-2 mos
11
Q
Rolls over
Grasps rattle
Works for toy
Babbies
A
3-4 mos
12
Q
Squeals
Laughs
A
4-5 mos
13
Q
Sits
A
5 mos
14
Q
Feeds self
A
7 mos
15
Q
Indicates wants
A
7-8 mos
