Pediatric History Taking (pages 8-9 in notes)

Question 1

What are questions you’d ask about During Pregnancy?

Answer 1

Any problems?
Bed rest?
Meds?
Drugs?
Alcohol?
Illnesses?
Traumas?
Position in utero?

Question 2

What are questions you’d ask about labor & delivery?

Answer 2

• on time?
• vaginal or c-section? spontaneous or induced?
• position of baby?
• time <3hrs- >20hrs
• any devices used?
• meds or procedures needed?
• birth height/weight/head size?

Question 3

What are questions you’d ask about post-natal?

Answer 3

• any problems?
• APGAR score?
• breathing (RDS)?
• ICU?
• Jaundice?
• Newborn exam ok?
• 1st urine/BMI?
• nutrition/nursing?

Question 4

What are the 4 questions about HABITS that are very important to ask?

Answer 4

• Any changes in attitude/personality?
• Any changes in appetite/feeding?
• Any change in sleep? night terrors?
• Any change in bowel/bladder habits?
• also ask if the child was injured from a trauma or is ill

Question 5

Infant conditions to watch for?

Answer 5

Congenital- (in utero/developmental): CP, feet, clubfoot, CHD, hearing, vision, brain, fetal alcohol
Birth Trauma- torticollis, brachial plexus, clavicle fx, brain injury, head injury, etc.
Genetic- downs, muscular dystrophy, etc.
Other- (colic, nursing difficulties, GER, etc.)

Question 6

Does this patient seem ILL checklist?

Answer 6

• fever? vitals normal? skin rashes? any signs of SEARCH? Mental status abnormalities?
• Growth normal? weight, height, head size, is anterior fontanelle normal?
• any developmental delays?
• any personality/attitude changes?
• any sleep changes? are they sleeping soundly?
• are their bodily functions WNL; any change from their normal?? BM 1/2days to 3-6/day
• urine: 6-8 wet diapers/day
• feedings every 2-4hrs; is there appetite good/normal?