3. Age group in pediatery
• Fetal period
• Neonatal period
• Infant period
• Toddler age
• Preschool age
• School age
• Adolescence
4.
5.
6.
7.
8. Different between pediatric and adult
in history taking.
• I. Content Differences
• A. Prenatal and birth
history
• B. Developmental
history
• C. Social history of
family - environmental
risks
• D. Immunization
history
• II. Parent as Historian
9. OBSTETRIC HISTORY
• • General informaAon
• • History of current
pregnancy
• • Past Obstetric history
• • Gynecological history
• Enquiry about other
systems:
• • Past medical
• and surgical history
• • Psychiatric history
• Family history
• • Social history
• • Drug history
• • Allergies
• • Summary
10.
11. 1.History of current pregnancy
• Dates as calculated from ultrasound.
• Single /mulAple (chorionicity)
• Detailed of presenAng problem.
• Have there been any other problems in this
pregnancy ?
• Has there been any bleeding , contracAons or
loss of fluid vaginally ?
12.
13.
14. 2• Past Obstetric history:
• 1. Date of delivery (or
pregnancy termina6on) 2.
Loca6on of delivery (or
pregnancy termina6on)
• 3. Dura6on of gesta6on
• 4. Type of delivery (or
method of terminaAng
pregnancy
• 5.Maternal complica6ons.
• 5. Dura6on of labor
(recorded in hours).
This may alert the
physician to the
possibility of an
unusually long or short
labor.
• 6. Type of anesthesia.
• 7.Newborn weight
• Fetal and neonatal
complica6ons.
15. 3.Gynecological history :
• Ø Periods: regularity.
• Ø ContracepAve history ,Oral contracepAves
taken during early pregnancy have been
associated with birth defects, and retained
intrauterine devices (IUDs) can cause early
pregnancy loss,
• infecAon, and premature delivery.
• Ø Previous infecAons and their treatment.
• Ø When was the last cervical smear?
16. • 4.Psychiatric history : Ø
Post partum blues or
depression. Ø Depression
unrelated to pregnancy. Ø
Major psychiatric illness .
5.• Family history :
• Ø Diabetes
,hypertension,
thromboembolic disease ,
geneAc problems,
psychiatric problems …
19. definition
• Neonate /newborn – a child in the first 28
days of life.
• Perinatal period –the one extending from 28
completed weeks of gestation of the foetus to
the end of the 7th completed days of life
• Term –a baby who is 37 completed weeks of
gestation to less than 42 completed weeks
20. Neonatal history
• Follows the same steps on how to take
paediatric history with more emphasis on the
perinatal, neonatal and maternal/obstetric
history
21. Neonatal history
• A general examination is not complete if a history
is not taken.
• The history should be taken from the mother,
together with the maternal and infant record book.
• Discussion with the staff who have cared for the
mother and infant is also important.
• The history will often identify clinical problems
and suggest what clinical signs to look for during
the examination.
22. The sections of a perinatal history
The maternal background:
– The mother’s age, gravidity and parity.
– The number of infants that are alive and the number that are dead. The
cause of death and age at death.
– The birth weight of the previous infants.
– Any problems with previous infants, e.g. neonatal jaundice, preterm
delivery, congenital abnormalities.
– The home and socioeconomic status.
– Family history of congenital abnormalities.
23. The sections of a perinatal history
• The present pregnancy:
– Gestational age based on menstrual dates, early obstetric
examination and ultrasound examination.
– Problems during the pregnancy, e.g. vaginal bleeding.
– Illnesses during the pregnancy, e.g. rubella.
– Smoking, alcohol or medicines taken
24. – VDRL (or RPR) and TPHA (or FTA) results.
Treatment if syphilis diagnosed.
– HIV status.
– Antiretroviral treatment, CD4 count and viral load
if HIV positive..
– Blood groups.
– Assessment of fetal growth and condition.
25. • Labour and delivery:
– Spontaneous or induced onset of labour.
– Duration of labour.
– Method of delivery.
– Signs of fetal distress.
– Problems during labour and delivery.
– Medicines given to the mother, e.g. pethidine, antiretroviral
treatment.
26. • Infant at delivery:
– Apgar score and any resuscitation needed.
– Any abnormalities detected.
– Birth weight and head circumference.
– Estimated gestational age.
– Vitamin K given.
27. Infant since delivery
– Time since delivery.
– Feeds given.
– Urine and meconium passed.
– Any clinical problems, e.g. hypothermia,
respiratory distress, hypoglycaemia.
– Contact between infant and mother.
28. • DEMOGRAPHICS
• MOTHERS NAME
________________________________________________
_______________________
• BABY’S DATE OF BIRTH ____________________
BABY’S TIME OF BIRTH _______________
• BABY’S BIRTH WEIGHT IN
GRAM___________________
• BABY’S CURRENT WEIGHTIN GRAM
______________ SEX ___________
• GESTATIONAL AGE
• MOTHER’S(OR FATHER’S/OTHER’S?)INSURANCE
STATUS
29.
30. History template
• PRESENTING
COMPLAINT:
• FEVER - DURATION
• POOR/NOT FEEDING -
DURATION
• JAUNDICE – DURATION
• DID NOT CRY AFTER
BIRTH
• LETHARGY - DURATION
• INCONSOLABLE
CRYING – DURATION
• SEIZURES
• LOW BIRTH WEIGHT
• BIG BABY
• RESPIRATORY DISTRESS
– DURATION
• BIRTH INJURY (STATE
TYPE)
• OTHER – STATE AND
GIVE DURATION
• HISTORY OF
PRESENTING
COMPLAINT:
31. History template
• COUGH
• DIFFICULTY
BREATHING
• NOISY BREATHING
• RUNNY NOSE
• DIFFICULTY
BREATHING
• POOR FEEDING
• SWEATING ON
FEEDING
• CYANOSIS
• OTHER (STATE)
32. History template
• VOMITING
• AGE AT FIRST PASSAGE OF
MECONIUM
• DIARRHOEA
• ABDOMINAL DISTENSION
• POOR FEEDING
• OTHER
•
• FAMILY AND SOCIAL HISTORY
•
• OTHER RELEVANT HISTORY OR
RELEVANT DETAILS
