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Pedia HX

This document contains information about a patient's medical history, including their present illness, past medical history, birth history, developmental milestones, immunizations, personal and social history, review of systems, physical examination findings, and impression. It includes sections on the patient's informant and reliability, chief complaint, history of present illness, past medical and surgical history, allergies, birth history, developmental milestones, immunizations, personal and social background, review of symptoms, vital signs, physical examination of multiple body systems, neurological examination, reflexes, and impression.

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211 views3 pages

Pedia HX

This document contains information about a patient's medical history, including their present illness, past medical history, birth history, developmental milestones, immunizations, personal and social history, review of systems, physical examination findings, and impression. It includes sections on the patient's informant and reliability, chief complaint, history of present illness, past medical and surgical history, allergies, birth history, developmental milestones, immunizations, personal and social background, review of symptoms, vital signs, physical examination of multiple body systems, neurological examination, reflexes, and impression.

Uploaded by

eyakoy
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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INFORMANT & RELIABILITY:

CHIEF COMPLAINT:
HISTORY OF PRESENT ILLNESS:

PAST MEDICAL HISTORY:


Medical problems/ Previous Hospitalizations:
Latest hospitalizations:
Infections and Medications Taken:
Allergies: ( ) food:

( ) Dengue Fever, ( ) Typhoid Fever


( ) Chicken pox, ( ) Measles
( ) drugs:

BIRTH HISTORY:
Antenatal: Prenatal check-up started at ____________ Place ___________________ TT:____ Infections
_______________________
Maternal Illnesses: ( ) bleeding
( ) preeclampsia/eclampsia ( ) UTI
Natal: Type Delivery ______________ Place ___________ Assisted by_____________ BW. __________Term _____ ( )
Resuscitation
Neonatal: APGAR Score: ______, color:______, abnormalities: __________, convulsions: ___________,
fever:________
Nutrition: Exclusive breastfeeding:_________, Mixed feeding:_______, Milk formula:__________ preparation
________water _____
Solid food: ______, Appetite: ________, Vitamins:____________________, Present
Diet:_______________________________
DEVELOPMENTAL MILESTONES:
Regards face: ______ Rolls over: __________ Sits alone: _____________ Creeps: _________Walks w/support:
_____________ Stands alone_________, Talked mama/papa__________ First teeth: _________ Walks alone
______________
Family History: ( )Hypertension, ( ) DM, ( ) Asthma, ( ) PTB, ( ) Epilepsy, Malignancies, ( ) Thyroid
disease, ( ) Hx of convulsions
IMMUNIZATION: ( ) BCG ( ) DPT ( ) OPV ( )Measles ( ) Hepa B ( ) Pneumococcal ( ) Rotavirus,
Others: _____________________
PERSONAL-SOCIAL HISTORY:
Birth Order: ________ Siblings: ________ Patients school status: ____________________________
Father: _____________________________
Age: ________ Occupation: ______________
Mother: ____________________________
Age: ________ Occupation: ______________
Guardian: ___________________________
Age: _________ Occupation: _____________
Daily Activities: _______________________ Environment:____________________________ Food
Handling________________
REVIEW OF SYSTEMS:
General: ( ) fever ( ) weight loss ( )changes in activity
Skin: ( ) rashes ( ) itchiness ( ) discoloration
Head: ( ) lesions ( ) scars ( ) headache
Eyes: ( ) crossing ( ) redness ( )discharges
Ear: ( ) pain ( ) discharges ( ) hearing loss
Nose: ( ) discharge ( ) sinusitis ( )colds
Mouth & Throat: ( ) sore throat/hoarseness ( ) dryness ( ) oral
lesions
Respi.: ( ) cough ( ) wheezing ( ) apnea ( ) cyanosis ( ) DOB
CV: ( ) murmurs ( ) chest pain

GI: ( ) anorexia ( ) vomiting ( ) LBM ( ) constipation ( ) bloody


stool ( ) abd.pain
GU: ( ) frequency ( ) dysuria ( ) changes in urine output ( )
hematuria
Hema./Lymph.: ( ) bleeding ( ) anemia ( ) jaundice ( ) swollen
glands
Neuromuscular: ( ) seizures ( ) loss of consciousness ( ) joint
pain ( ) weakness
Psych.: ( ) mood changes ( ) sleep problems

IDENTIFYING DATA
Name: ___________________________________________ Age/Sex: __________ Address:
_________________________________
Religion: _________________________ Nationality: ____________________________Date/Time:
___________________________
Referral: __________________________________ Number of Admissions: ______________ ROD:
___________________________

PHYSICAL EXAMINATION:
General Survey:
V/S:

BP =
Temp =

HR =

RR =

Wt =

Ht =

Skin:

Head Circ =
Abd. Circ =
Chest Circ =
GU:

HEENT:
Neck:

Extremities:
Anus:

Chest & Lungs:


Heart:
Abdomen:
NEUROLOGIC EXAMINATION:
Mental Status :
Behaviour: LOC:_______________, Intellegence ____________, emotional status _________________________
Cranial Nerves:
CN I: ( ) anosomia ___________
CN II: light response __________
CN III, IV, VI: follows gaze, drooping
________________
CN V: facial sensation, corneal reflex, jaw jerk
___________
CN VII: facial symmetry ____________
CN VIII: sound response ___________
CN IX: gag reflex __________________
CN X: swallowing ___________________
CN XI: shoulder shruge________
CN XII: protrusion, tremor, & strength of tongue
________
Cerebellar Function: Finger-to-nose
____________________
Romberg Sign
____________________
Motor: Muscle bulk: __________ Muscle tone:
__________
Neonatal Reflex:

Strength (1-5):
(0,+1,+2,+3)

DTRs:
R

Upp
er
Low
er

Sensory: Light touch ______ Pain ______


Temperature ______
Meningeal signs: ( ) Neck rigidity ( ) Kernigs ( )
Brudzinskis
Autonomic functions: Urinary Incontinence
___________
Bowel Incontinence
____________

Ages
Palmar Grasp
Plantar Grasp
Moro/ Startle
Asymmenteric
Tonic
Positive
Support
Rooting
Trunk
Incurvation/
Galants
Placing
&stepping
Landau
Parachute
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
( )
IMPRESSION:

Superficial Reflexes

B-3-4m
B-6-8m
B-4-6m
B-2m
B-2-6m
B-3-4m
B-2m
Bvariable
B-6m
4-6mnone

( ) Abdominal
( ) Cremasteric
( ) Plantar

_______________________________

Pedia Clerk On Duty:

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