1st Lecture Practical Pediatric Assessment PDF

**History Taking** 1. **Child's Information:** The child\'s birth date (age), religion, address, parent education, phone number and date of admission can be obtained from the admission form, Source of taking History. 2. **Chief compliant:** Identify the child\'s primary problem or reason fo...

**History Taking** 1. **Child's Information:** The child\'s birth date (age), religion, address, parent education, phone number and date of admission can be obtained from the admission form, Source of taking History. 2. **Chief compliant:** Identify the child\'s primary problem or reason for hospital admission, Stated in the parent\'s or child\'s exact words. Elicit the chief complaint by asking open-ended, neutral questions such as: "Why did you come here today?" *Avoid labeling-type questions such as: "How are you sick?" or "What is the problem?"* 3. **History of present illness or injury:** Obtain a detailed description of the current health problem to include characteristics: as describe below: a. **Onset:** sudden or gradual, pervious episode, date and time began b. **Type of symptom**: pain, itching, cough, vomiting, runny nose, diarrhea, rash, etc.... c. **Location:** generalized or localized- anatomically precise d. **Duration:** continues or episodic, length of episodes e. **Severity:** effect on daily activates e.g. Interrupted sleep, decreased appetite , incapacitation f. **Influencing factor:** what relives or aggravates symptoms, what precipitated the problem, recent exposure to infection or allergen g. **Past evaluation for the problem:** laboratory studies, physician's office or hospital where done, results of past examinations h. **Previous and current treatment:** prescribed and over the counter drugs used, complementary and alternative therapies, other treatment tried (heat, ice, rest) response to treatments. 4. **Past history:** a. **Prenatal condition:** - Mother age, health during pregnancy, prenatal care, weight gain, special diet, expected date of birth. - Detailed illness, medication, complication, hospitalization b. **Intra partum- description of birth** - Site of birth (hospital, home and birth center) - Labor induced or spontaneous, length of labor - Vaginal or cesarean birth. - Length of pregnancy, Single or multiple **Condition of baby at birth** - Weight, Apgar score, cried immediately - Need to incubator, resuscitation, oxygen, ventilator - Any abnormality detected, meconium staining c. **Post-natal condition:** - Difficulty in the nursery -- feeding, respiratory difficulties, jaundice, cyanosis, rash, seizure. - Length of hospital stay - Breast or bottle fed, - Medical care needed at first week -- re-admission to hospital 5. **Previous Illnesses:** - Common communicable diseases: measles, rubella (German measles), chickenpox, mumps (swollen salivary glands), pertussis (whooping cough), diphtheria (دةردةكؤبان), tuberculosis. - Operations (surgeries)/duration - Hospitalizations - Blood transfusion a. **Allergies**\--to food, medication, animals, insect bites, or other exposures, and the type of reaction (e.g., respiratory difficulty, *rash,* hives, itching). b. **Immunization**\--review dates of immunizations were received and any unexpected reactions. c. **Activities and Exercise**\-\--physical mobility and limitations, adaptive equipment used; play and/or sports activities. d. **Nutrition-**formula-fed or Breastfed; if breastfed, for how long, type and amount of daily formula intake; when solid foods were introduced; eating and snacking habits, variety of foods consumed. e. **Sleep**-length and timing of naps and nighttime sleep; nightmares (dreams) or night terrors, other sleep disturbances; where the\' child sleeps, and bedtime rituals. 6. **Social History** - Living circumstances: place and nature of residence - Economic conditions - Parents occupations and marital status - Household pets - Potential exposures to toxins in home, for example, cigarette smoke exposure - Water source 7. **Developmental History** a. Ages at which milestones were achieved and current developmental abilities - smiling, rolling, sitting alone, crawling, walking, running, 1^st^ word, toilet training, riding tricycle, etc. (see developmental charts) b. School-present grade, specific problems, interaction with peers c. Behavior - enuresis, temper tantrums, thumb sucking, pica (بيزو (, nightmares etc. 8. **Family History** Obtain a list of the major familial and hereditary diseases in three generations of family members, including the parents, grandparents, aunts, uncles, cousins, child, and siblings. 9. **Review of Systems**