儿科病史采集英文版

null Pediatric History Pediatric History Fundamentals of DiagnosisFundamentals of Diagnosis Skillful history-taking Careful physical exam Keen powers of observation Wise selection of “other exams” x-ray, labs, etc. Good clinical judgmentLOOK – LISTEN – FEEL…Tips… Definite No-No’sTips… Definite No-No’sNever be critical of another doctor’s diagnosis or treatment suggestions Never allow a child who has been brought to you for care to leave without it do what you have to do, despite protests from the child Never allow a child to be rewarded for being sickIdentifying data Identifying data Name Nickname Birth date Parents’ names (last name may be different Telephone number (home/work) Address8Format of Case file Format of Case file Chief Complaint History of Present Illness Personal history Birth History Feeding History Developmental History Past history Past Medical History Vaccination History Family History 2Chief ComplaintChief ComplaintThis is what the informant (either the parent, patient) states in their own wordsHistory of Present IllnessHistory of Present IllnessThis is the most important part of the document. List items in order of appearance Write in a narrative fashion (tell the “story” why the patient is there) History of Present IllnessHistory of Present Illness Sequence of events - what happened next? when was he last well? - what was the first thing you noticed wrong? Follow-up enquiry , eg pain - site, nature, frequency, radiation, aggravating & relieving factors, associated features eg seizure – onset, characteristics, duration, post episode Personal history Personal history Aspects of history unique to pediatrics Birth History Feeding History Developmental History Birth HistoryBirth History gestation, mode of delivery – Why? birth weight, (AGA, SGA, LGA) Apgar scores Newborn problems: prematurity, respiratory distress, jaundice and infections Feeding HistoryFeeding History Breast /bottle, reason for changes, if any Present diet and appetite Age of introduction of solids Age child achieved 3 feedings per day Present feeding patterns Any feeding problems Age weaned from breast or bottle Type of milk and daily intake Food preference Ability to feed self Special diets - why? Developmental HistoryDevelopmental HistoryCommonly used developmental milestones Major motor Minor motor Language Social/Adaptive Past historyPast historyPast Medical History Illnesses Hospitalizations Communicable diseases Injuries Allergy Vaccination History Vaccine Schedule (China)Vaccine Schedule (China)if no vaccinations always ask why