Informant: A.

Medical illnesses – date – complications – medications –

% reliability number of days – improvement with interventions – TB
exposure
PATIENT’S PROFILE B. Immunization
Patient’s name ADVERSE REACTIOS FOR EACH
Age BCG – after birth – 1 dose – L deltoid - ID
Sex DPT – 2,4,6 months – 1,2,3 doses – thigh – IM
Nationality OPV – 2,4,6 months – 1,2,3 doses – oral
Religion AMV – 9 months – 1 dose – SQ
Birthdate HepB – 0,2,6 months – 1,2,3 doses – thigh – IM
Birthplace C. Medications and Vitamins (dose and frequency)
Address D. Allergies/ drug reactions
Number of times admitted E. Operations, accidents, hospitalizations – date –
Date admitted complications – medications – days in hospital – condition
Chief complaint upon discharge
If previously hospitalized, write a summary of
PERSONAL HISTORY each hospitalization and condition from time of discharge
Prenatal History to readmission
Mother’s age F. newborn screening results, blood typing
OB score G. preventive check ups (frequency, regular, condition
1st prenatal check up – where, when, who and if regular? reported)
General condition of the mother H. Nutrition
HPN Breastfeed (purely, until what age, reason for
Diabetes stopping)
Asthmatic Mixed Feeding
Previous hospitalizations Bottlefeed (age started)
Previous illnesses/infections during pregnancy Supplemental and complemental feeding
TT vaccine status (doses and when given) Type of formula and dilution
Alcohol Amount per feeding
Smoking Frequency/interval of feeding
Toxemias Age of weaning, what foods
Hormone therapy Vitamins (name, dose)
Radiation I. Growth and Development
Medications
Vitamins – folic acid, iron PSYCHOSOCIAL HISTORY
Bleeding A. Sleep patterns (how long at night, naps during the day)
Threatened abortion B. Elimination (regular bowel mov’t, frequency, char of stool)
C. Thumbsuck, enuresis, nail biting,. Breathholding, temper
Natal History tantrums, masturbation, destructive aggressive behavior, toilet
Duration and circumstance of labor training
Analgesia used D. birth rank, household composed of
Outcome of the baby Name – age, relation to px, occupation
Home or hospital delivery E. Primary care provider, who prepares the food, illnesses of
Assisted by: OB, midwife, TBA the care provider, smoking, exposure to other chemicals?
Type of delivery
Meconium staining FAMILY HISTORY
Complications Parents alive and healthy? Illnesses? HFD-HPN, asthma, DM?
Birth weight Mother’s previous pregnancies and attitude towards them
APGAR Size of family
Age of gestation – indicate weeks (term, preterm, postterm) Health and other problems of other children
Good cry Living conditions
Birth rank Housing (floor area) (materials: heavy, light, mixed)
Economic status
Postnatal History Educational attainment of family
Condition after birth Important diseases in the family (consanguinity, mental
Jaundice, convulsions, resuscitation, pallor, dyspnea, illness, heart disease, infections)
congenital defects (onset, duration, intensity, interventions) Drug abuse, alcohol abuse
Number of days in hospital
Medications given HPI
eye ointment Onset, location, duration, characteristic, aggravating factors,
vitamin K relieving factors, treatment, scale, radiation, frequency, setting
it occurred, associated manifestations
DEVELOPMENTAL MILESTONES Mouth and Throat: pink buccal mucosa, no pharyngeal
Holds head steady while sitting erythema, # of teeth, angular stomatitis, gag reflex, staining of
no head lag teeth, tongue normal and cobblestoning of posterior pharynx,
Tonic neck reflex gone exudates, tonsils,
Sits with support Neck: supple, midline, trachea, lymphadenopathy, no
Sits without support webbing, thyroid palpable
Rolls back to stomach C/L: symmetric ECE, no deformities, clear vesicular breath
Creeps sounds, no rales, tachypnea, dyspnea,
Pulls self to stand Heart: PMI, HR, distinct s1 and s2, regular rhythm, no
Stand with support murmur, femoral and dorsalis pedis artery, forceful, regular
Walks with hand held Breast: normal with some fat
Stand alone Abd: globular, protruding , liver edge, NABS, soft, no masses,
Walks alone no splenomegaly
Crawls upstairs GUT: grossly male, no external genitalia anomalies,
Walks up and down stairs (alternating feet or 2 feet at a step) descended testes, penile discharges, edematous scrotum,
Runs tanner staging
Hops on foot Anus and Rectum: patent anus, diaper rash
Tooth eruption Back: no spinal dimple
Ext: full range of motion, no lesions, pink nailbeds, strong
Grasps rattle peripheral pulses, normal range of motion , spine straight, gait
Reaches for objects normal, edema
Palmar grasp gone Neurologic:
chew Mental status: happy cooperative
Transfer objects from hand to hand Cerebral: active, alert, playful
Holds bottle Cranial Nerves –
Pincer grasp 2: bilateral blinking to PLR and ROR of eye
Tower of 2 cubes 3,4,6: EOM
Tower of 6 cubes 5: good suck
Imitates cross 7. eye closure, and symmetry of facial
Write alphabet creases on crying
Attempts to use a spoon 8. turns to source of sound
Uses a knife 9,10: good swallowing reflex
Prints first name 11:symmetry of shoulders
Eye follows past midline 12: feels well
Feeds self Cerebellar: normal gait, good balance,
DTR: normal and symmetric throughout
Social smile Sensory: deferred
Coo
Babble Primitive reflexes:
Mama dada a. Galant and Tonic Neck – B to 2 months
Peak a boo b. Rooting and Palmar – B to 3-4 months
Stranger anxiety c. Moro – B to 4 months
d. Plantar – B to 6-8 months
Stares momentarily at spot where object disappeared e. Postive Support – B-2 to 6 months
Object permanence f. Parachute – 4-6 months to unknown
Pretend play g. Landau – B to 6 months
h. stepping on grass – B to unknown (best at 4th day
PHYSICAL EXAMINATION old)
General survey: alert, conscious, irritable, active, energetic,
playful, afebrile, pale-looking, carried by mother, not in
respiratory distress, with the following vital signs:
RR HC weight
HR CC height
T SFT BMI
Skin: pink, good turgor, no rashes, bruises, dry skin
Head: abundant/sparse hair, no scalp lesions, normocephalic
Face: no dysmorphic features
Eyes: white sclera, pink palpebral ocnjunctiva, PLR,
symmetric, normal EOM, pupil size,
Ears: normal pinna, discharges, impacted cerumen, tympanic
membrane – no alteration in cone of light,
Nose: normal nares, discharges, pink mucosa, septum midline