For the medical education and practice

1. Prepare by Thobias B Msomi

2. 
General History In
Pediatrics

3. 
Name :
For Identification & To Be Familiar With Patient .
Age :
Certain Diseases Are Related To Certain Age Groups .
Sex :
Some Diseases Are More Common In Males / Females .
1- Personal History :

4. 
Nationality :
Certain Diseases Are Related To Certain Countries .
Home & Residence :
Certain Diseases Are Related To Certain Areas .
Informant : Who Give You The History .
Date Of Admission .

5. 
In Patient's Own Words .
Write The Duration .
Sort Them In Chronological Manner .
Example : Abdominal Pain / 1 Day .
2- Chief Complaint ( C/O ) :

6. 
A- The Patient Is Known Case Of ……. ( Chronic
Disease ) .
B- The Patient Was Well Till / On Usual Status Till
……… ( Hours - Days - Weeks - Months ) Back When
He/She Started To Has ………………. ( Complaint ) .
C- Analysis Of Complaint :
3- History Of Presenting Illness
( HPI ) :

7. 
C- Analysis Of Complaint :
Remember this is part of but in more details History
Of Presenting Illness ( HPI )

8. 
1- Fever :
Onset , Course , Duration , Pattern , Grade , Associated
With ( Rigors - Convulsions - Skin Rash ) .
2- Wight Changes :
Onset , Course , Duration , How Much ?
I) General Symptoms :

9. 
1- Abdominal Pain :
Site , Onset , Course , Duration , Character ( Nature ) ,
Radiated / Referred / Shifted , Aggravating &
Relieving Factors , Severity ( Measured By :
Interfering With Daily Activities , School Missing ) ,
Associated Symptoms .
II) GIT Symptoms :

10. 
2- Vomiting :
Onset , Course , Duration , Content , Color , Odour ,
Relation To Eating .
3- Diarrhea :
Onset , Course , Duration , Content , Color , Odour ,
Frequency , Consistency .

11. 
4- Constipation :
Onset , Course , Duration , Type ( Partial - Complete ) ,
Presence Of Anal Pain .
5- Jaundice :
Onset , Course , Duration , Who Notice ? , Stool Color ,
Urine Color , RUQ Pain .
6- Bleeding :
Onset , Course , Duration , Content , Color , Odour .

12. 
1- Cough :
Onset , Course , Duration , Character , Frequency ,
Aggravating & Relieving Factors , Sputum , Relation
To Position .
2- Sputum :
Onset , Course , Duration , Color , Odour , Amount ,
Relation To Position , Consistency .
III) Cardio-Pulmonary
Symptoms :

13. 
3- SOB :
Onset , Course , Duration , Type , Severity , Grade .
4- Chest Pain :
Site , Onset , Course , Duration , Character , Radiation
, Aggravating & Relieving Factors , Associated
Symptoms ( Abdominal Pain , Nausea , Vomiting ,
Sweating , Fever ) .

14. 
5- Wheeze :
Onset , Course , Duration , Occurrence ( Exposure -
Exertion ) .
6- Cyanosis :
Site ( Oral - Extremities ) , Onset , Course , Duration ,
Occurrence ( Rest - Exertion ) , Relation To Feeding ,
Associated With ( Sweating - Cold Extremities ) .

15. 
7- Runny Nose .
8- Earache .

16. 
1- Symptoms Suggestive Of Higher Functions
Involvement : Onset , Course , Duration , Type .
2- Symptoms Suggestive Of Cranial Nerves
Involvement :
Onset , Course , Duration , Type , Function Impairment
( Sensory , Motor , Gustatory ) .
IV) CNS Symptoms :

17. 
3- Weakness :
Site , Onset , Course , Duration , Grade , Features Of
Increased Intra-Cranial Pressure ( ICP ) .
4- Abnormal Movement :
Site , Onset , Course , Duration , Type , Features Of
Increased ICP , Sphincter Function .

18. 
- Symptoms Of Higher Function :
Consciousness , Memory , Speech , … Etc.
- Symptoms Of Increased ICP :
Headache , Blurred Vision , Projectile Vomiting .
** Notes :

19. 
1- Pain :
Site , Onset , Course , Duration , Character , Radiation
, Aggravating & Relieving Factors , Severity .
2- Polyuria :
Onset , Course , Duration , Frequency , Volume .
3- Dysuria :
Onset , Course , Duration , Baby Crying .
V) Genito-Urinary Symptoms :

20. 
4- Discharge :
Onset , Course , Duration , Color , Amount , Odour ,
Consistency , Itching .

21. 
- Bone / Joint / Muscle Pain :
Site , Onset , Course , Duration , Character , Radiation
, Aggravating & Relieving Factors , Severity , Loss Of
Movement , Trauma , Stiffness ,
VI) Musculo-Skeletal
Symptoms :

22. 
1- Skin Rash :
Onset , Course , Duration , Distribution , Type .
2- Itching :
Onset , Course , Duration .
3- Hyper/Hypo Pigmentation :
Onset , Course , Duration .
VII) Skin Symptoms :

23. 
D- Review The Symptoms Of The Affected System .

24. 
General :
Weak Cry , Poor Feeding , Child Activity .
CNS :
Headache , Higher Functions , CNs , Loss Of Sensation ,
Weakness , Abnormal Movement .
GIT :
Dysphagia , Nausea , Vomiting , Abdominal Pain ,
Jaundice , Change In The Bowel Habits , Bleeding .
E- Review The Symptoms Of
Other Systems :

25. 
Cardio-Pulmonary :
Cough , Dyspnea , Chest Pain , Wheeze , Cyanosis .
Urogenital :
Loin Pain , Dysuria , Polyuria , Hematuria , Discharge .
Musculoskeletal : Pain , Loss Of Movement ,Stiffness.
Skin : Rash . Itching , Pigmentation .
Hematology :
Easy Fatigability , Petichiae , Gum Bleeding , Pallor .

26. 
F- Hospital Course ( Investigations & Medications ) .