Socio-Demographic History

Name:

Age:

Sex: 

Child born of consanguineous or non-consanguineous marriage:

Religion:

Address: 

Migrant/ Native:                              

Informant:

Date of Admission:

Chief Complaints

• Mention the complaints and the duration for which the patient has come to the OPD or hospitalized. 

Present History: 

Describe the chief complaints of the child with onset, duration and progress in detail.

1. Does the child have DANGER SIGNS?

• • • Is the child able to drink or feed?

    • is the child lethargic or unconscious

    • Does the child vomit everything out?

    • Has the child had convulsions?

2. Does the child have COUGH OR DIFFICULT BREATHING

• If Yes,  since how long

• Is there bluish discolouration of lips and extremities

2. Does the child have FEVER? (Malaria, Dengue, Measles)

• • • High or low grade fever

    • Whether associated with chills

    • Since when, is it present?

    • Is it present  everyday or at certain times of the day

    • Is there any rash / bleeding from any site?

    • Does the child have cold extremities?

    • Is there severe abdominal pain?

    • Does the child have runny nose, cough, congestion in the eyes?

    • Does the child have a rash?

4. Does the child have DIARRHOEA?

• • • Diarrhoea – Onset - since when

    • Frequency of stools -number of stools passed

    • Consistency of stools - Change in consistency in stools 

    • Blood in stools 

    • Sticky stools

    • Vomiting – since when, number of times vomited  

    • Abdominal pain- since when, type of pain mostly colicky (if child is able to tell), location of pain 

    • Fever - associated with invasive pathogens  

5. Does the child have an EAR PROBLEM?

• Ear Pain/Tugging of the ears

• Ear discharge - colour , duration

6. Does the child have any FEEDING PROBLEM?

• Any feeding problem

• (If the child has any feeding problems, The dietary history should be presented in the present history. Refer to dietary section for the questions to be asked.)

7. History of TREATMENT OR HOME-REMEDIES

• • Ask whether any treatment was taken. 

  • If yes, details of treatment - what was given, by whom, for how long etc.

  • Were any home remedies tried?

Past History

1. Respiratory infection in the past and treatment taken.H/o Frequent nebulisation.

2. Ask for history of diarrhoea in the past and treatment taken.

3. Other illnesses like HIV infection, TB, Asthma, COPD

4. Measles within the last 3 months.

5. Hospitalization in the past.

6. Surgery in the past.

Personal History

1. Sleep - Does the child sleep soundly or is the child restless and irritable.

2. Appetite -During this illness, has the child’s feeding changed? If Yes, how? Is the child appetite normal or reduced.

3. History of allergy. 

4. History of any adverse drug reactions. 

5. History of any adverse event following immunisation.

Family History

1. History of similar illness in family members.

2. History of chronic cough in the family members.

3. No history of genetic or chromosomal abnormalities.

Immunisation History

Ask for history of Immunisation and check if child is immunised upto date as per the national immunisation schedule.

Mother's Past Obstetric History

• Gravida _____ Para _____Abortion _______Live birth _________ Stillbirth ____

• Interval between pregnancy

• Family Planning method being used

Birth History of the present child

Ask the mother the details of the antenatal, intranatal and postnatal period at the time of pregnancy and birth of the present child.

Antenatal history when she was pregnant with  this child

• Registered in which trimester

• Iron Folic Acid

• Td Injection given

• Fever or rash during pregnancy

• History of raised blood sugars or raised BP during pregnancy

• Failure to gain weight during pregnancy

• Working status at the time of pregnancy

• Mental stress

• Age of mother during pregnancy

Intranatal history

• Term of delivery

• Place of delivery 

• Nature of delivery

• Any complications during delivery?

• Birth weight of baby

• Did baby cry immediately after birth?

• When was breast feeding started?

• History of any prelacteal feeds

Postnatal history

• Any complications in the mother?

• Colostrum given to baby

• Exclusive breastfeeding practiced

• Age of initiating  complementary feed

• Age till which  breastfeeding done

Development history of child

• Gross Motor Development

• Fine Motor Development

• Social and Adaptive Development

• Language Development

• Is development of age appropriate skills achieved:

SOCIO-ECONOMIC HISTORY

• Details regarding the following should be obtained in history.

  • No of person/s living in family and age wise distribution of family and their relationship.

  • Type of family

  • No. of earning family members and total income.

  • Head of the family.

  • Educational status and Occupation of the head of the family.

  • Total family income

  • Per capita Income

  • Mother or caretaker’s educational status and occupation.

• Draw the family tree after obtaining the details of the family members to depict the relationship between different individuals of the family.(Pedigree chart)

• Classify the socio-economic status using Modified B.G.Prasad Classification or Kuppuswamy Classification.

Environmental history:

1. Housing

Ask and Elicit the following information.

1. • Floor, walls and roof of the house made of (to determine Kutcha or pucca house).

   • Overcrowding: Floor space area of house and No. of rooms (to determine overcrowding).

   • Ventilation: No. of windows, doors and placement of doors and windows  (to determine ventilation).

   • Lighting: Artificial lighting required during the daytime for reading or doing household chores.

   • Proximity of house to factories, industries or massive construction sites (to determine exposure to air pollution).

2. Water Supply

• • Source – Municipal water/tanker/well

  • Continuous/intermittent

  • Storage of water for household purposes

  • Storage of water for drinking purpose

  • How is stored water withdrawn for drinking purposes?

  • Water Purification methods adopted

3. Waste disposal

• • Stored in house prior to disposal – kept covered or not

  • Frequency of disposal from house

  • Waste disposal - Municipal authorities come and collect from house or is it dumped in some common place and later collected by municipal authorities

4. Latrine

• • Attached latrine / Common latrine

  • Defaecation practices - use of toilet or open air defaecation

5. Pets

• Any pets in the household

6. Pests/rodents

• Present /absent. If present mention which ones.

7. Sanitation

• • Cleanliness of house

  • Cleanliness of surroundings

  • Sites of stagnant water in and around house

8. Kitchen

• Facility for storage of cooked and raw food

• Fuel used for cooking

• Cooked food eaten on same day 

Socio-cultural factors

Socio-cultural practices pertaining to child care.

1. 1. Feeding related

      • adoption of bottle feeding

      • adoption of commercially prepared baby foods

   2. Illness related - like withholding of food and fluids during diarrhoea

   3. Home remedies

   4. Health seeking behaviour

Dietary History

1. Breastfeeding

   • Breastfeeding - Yes / No

   • Feeds during the night - Yes / No

   • Frequency during 24 hours period

   • Does the mother have any pain while breastfeeding?

2. Bottlefeeding

   • Bottlefeeding - Yes/No

   • Which milk?

   • Diluted or not diluted

   • How much quantity consumed

3.  Other food or fluids

• Receive any other foods or drinks (Mention the details) - Take the dietary history of the child in 24 hours on a typical day when the child is well. 

• Mention about consumption of fruits and non-vegetarian food which might be consumed weekly or occasionally.

• Frequency of meals

• Quantity per feed or day

• What is used to feed the infant?

• Does the child receive his own servings?

• Who feeds the child and how?

Calculate intake of Calories and Proteins and compare with recommended intake to check if intake adequate, inadequate or excess.

General examination:

1. Consciousness/unconsciousness

2. Alert/lethargy/ decreased body movement 

3. Cooperative / Restless and irritable 

4. Abnormal movement - Seizures/Jitteriness

5. Wasting - Generalised wasting / visible severe wasting /Skin folds on buttocks/baggy pant/ Appearance - old man/monkey appearance; moon face/Hair - color, lustreless, sparse, depigmented, easily pluckable

6. Shape of the skull - normal / frontal bossing / softening of skull (craniotabes)

7. Anterior and Posterior Fontanelle - Open/close;  bulging, depressedu or normal

8. Eyes 

• Sunken 

• Pallor

• Icterus

• Spots, conjunctival / corneal xerosis / corneal ulceration - Signs of vit A deficiency

• Redness of eyes, pus draining of the eye, clouding of the cornea

9. Ears 

• Pus draining from the ear

• Tenderness and swelling behind the ear

10. Nose 

• Rhinitis

• Nasal flaring

•  Deviated nasal septum

• Grunting 

11. Mouth 

• Angular stomatitis

• Cheilosis

• Ulcer or white patches in the mouth

• Are the  ulcers deep and extensive

• Koplik’s spots seen 

• Oropharynx - Normal tonsils / Enlarged tonsils

• Posterior Pharyngeal Wall - Normal / Inflammed 

• Tongue - Pallor / Glossitis / Dry

• Palate - cleft palate 

• Lips - cleft lip,  cyanosis       

• Teeth: normal, cavities, loss of enamel, pigmentation on teeth, no. of teeth

12. Nails - Look for Clubbing 

13. Palm - Look for Palmor pallor and Yellowish discoloration

14. Skin examination

• Dry scaly skin

• Ulcers in flexors

• Gangrenous lesions

• Pustules, boils, 

• Depigmentation, desquamation (flaky paint dermatosis)

• Petechiae, purpura, ecchymosis.

• Check appearance and distribution of rash if any (Measles rash)

• BCG scar 

• Skin Pinch Test in case of diarrhoea: skin pinch goes back very slowly/ slowly/immediately

• Umbilicus - is it red or draining pus 

15. Spine and back - Any abnormalities

16. Foot examination - 

• Oedema feet

• Grading of Pedal Oedema

• Yellowish  discolouration of sole

17. Look for Generalised lymphadenopathy 

18. If the child has fever - look or feel for stiff neck / neck rigidity (if child has fever)

19. Response when offered to drink - drink eagerly. thirsty / not able to drink or drinks poorly.

20. Tourniquet test (if dengue is suspected)

21. Temperature

22. Pulse

23. BP

24. Respiratory Rate

25. Anthropometry

• Head Circumference

• Weight

• Height/Length

• Mid upper arm circumference

• Chest circumference

OBSERVE BREASTFEEDING, IF ANY DIFFICULTY IN BREASTFEEDING REPORTED

If there is any difficulty in breastfeeding, observe whether the attachment is good (conclude after observing the four signs of good attachment)  and suckling is effective (slow deep sucks, pausing sometimes)

EXAMINE MOTHER’S BREAST IF PAIN IS REPORTED WHILE BREASTFEEDING

If the mother has reported pain while breast feeding, look for flat /inverted nipples, sore nipples, engorged breast or breast abscess.

Systemic Examination:

Cardiovascular system:

1. Inspection

2. Palpation

3. Percussion

4. Auscultation - S1, S2 normal, no murmurs

Respiratory system:

1. Inspection

• check for chest indrawing (to rule out possible bacterial infection/jaundice)

• position of trachea (Trail sign), apex beat

• chest symmetry

• movement of chest: rate (look for fast breathing), rhythm, use of accessory muscles

• Look and listen for stridor

2. Palpation

• Position of trachea, 

• Decreased chest expansion or asymmetry,

• Lymphadenopathy, increase tactile fremitus

3. Percussion

• Normal : resonant), dull note, Hyper-resonant

4. Auscultation

• • Decreased breath sound

  • Bronchial breathing normal vesicular, 

  • Added sound rales, wheeze, crackle etc

Alimentary system:

1. Inspection: 

2. Palpation : 

3. Percussion: 

4. Auscultation:

Central Nervous system:

1. Sensory System

2. Motor System

Case Summary:

• • Summarise in short the relevant demographic data, results of history taking and findings of clinical examination and epidemiological factors.

Differential Diagnosis: 

• Allergic rhinitis

• Pneumonia

• Asthma

• Bronchitis

• Whooping cough

• Pulmonary oedema due to cardiac diseases

Provisional Diagnosis:

• (Analysis of History. Physical Examination, Case Summary): This is made on the basis of positive findings and other relevant history stating the differential diagnosis.

Proposed Investigations: 

Pharmacological Management:

Non-Pharmacological Management:

1. Dietary advice:

2. Immunisation:

3. Environmental sanitation:

4. Personal Hygiene:

5. Follow-up:

6. Educate on danger signs when mother has to return: