In any pediatrics case: always CONSIDER child ABUSE / NEGLECT in DDx (report to CAS)

1) Introduction + Identify the Guardian

2) Chief complain: What brings you in today?

3) SOCRATES: Always r/o infections in Associated symptoms;

• Constitutional symptoms! 

• R/O infection:

4)Past medical Hx: Hospitalizations & blood transfusions, trauma & surgeries

5) Medications: Prescription, OTC, herbal remedies

6) Social: Travel etc..

7) BINDE: 0 to 6 years old

Birth/Pregnancy

• Was your pregnancy planned? If no (social issues)

• Were you having regular follow-up visits? How about U/S? Was it normal?

• During your pregnancy, did you have any illness (like fever or rash or contact with sick kids/pets), any meds or smoking/alcohol/drugs

• Any hepatitis B, HIV, GBS swab,

• Whats your and his blood group

• Was your baby full term or not/ vaginal or c-sec

• If c-section (why? Was there any complication? Abnormality?)/ If vaginal (was it difficult labour?/ any complications)

• Did your baby cry immediately or not? Do you know what his Apgar score was? Did he need special attention? When did you leave the hospital?

• Were there any bruises or swellings on your baby’s body?

• Were you told that your baby had any special features?

• After delivery, did you have any fever / discharge? Did you take any medications?

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Immunizations:

• Are your baby’s shots up-to-date?

• If Yes: when was the last shot?

• No: ask about any reason for that?

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Nutrition:

• Whats the Height and Weight today?

• Height and Weight at birth?

• Access to growth charts

Diet:

• What do you feed your baby:

•  Breast feed _ if more than 4 months: • Any iron supplement? • Any Vit D supplement? over breast feeding?

• Formula: • Since when? _ if since birth: any reason that you chose formula / • Which formula? Any recent change in formula?

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Note: For any case of chronic diarrhea:

• 1) Do you give him solid food; biscuits / bread / cereal?

• 2) Which started first? The diarrhea or this new food?

• 3) How many diapers do you change per day? (normally 5 – 6)

 

Development: "Now I would like to ask you some questions about the kind of activities that your child can do to assess your child's development" (Ask about the developmental Milestones)

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Environment:

• How do you feel being a new mom? How do you feel about your baby? Hows your mood (u look depressed)

• With whom do you live? How is the relation between you? (relationship between partner and baby)

• Other children in the house

• Financial situation

• House or Apartment

• Smoke/Alcohol/Drugs at home

• Mental illness in house

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HEADSSS: 12-18 years old

Home:

• Who do you live with

• Are they supportive

• Any siblings

 

Education:

• What grade? Do you enjoy school

• Hows your grades

Activity:

• Hobbies

• Operate machinery (epilepsy)

Diet:

• What do you eat

• Changes in weight

Suicide:

• Hows your mood

• Any chances you might hurt yourself

Sexual Activity:

• Are you sexually active?

• How many partners

• Do you practice Safe sex?

S/A/D:

• Smoking/ drinking/ Drugs