Anamnesis

(recollection, a patient case history)

Sugianto

Identifying information

Age
Sex
Date of interview
Informant
(birthdate, race, religion, nationality)

Chief complaint
Present illness
Review of systems
Past history
Family history
Birth history
Immunizations
Growth and development
Feeding
Physical examination


1. Chief complaint

The specific reason for the childs visit the clinic or hospital.

6 guidelines determine appropriate recording of the chief
complaint:
1. it is limited to a brief statement,
2. it is restricted to one or two symptoms,
3. it refers to a concrete complaint,
4. it is recorded in the childs or parents own words,
5. it is avoids the use of diagnostics terms or translations,
6. it state the duration of the symptoms(e.g. runny nose for 5
d., cough for 3 d)

2. Present illness

A narrative of the chief complaint from its earliest onset through
its progression to the present.
4 major components are:
details of onset,
complete interval history,
present status,
reason for seeking help now.



2. Present illness

Review of systems
1. General overall state of health, unexplained weight gain or
loss, fevers, chills, night sweats(unrelated to climatic
conditions), frequent infections.
2. Integument pruritus, jaundice, cyanosis, pallor, purpura,
petechiae, edema, rash, eruptions.
3. Head headaches, dizziness, injury, a small head, a large
head.
4. Eyes poor vision, glasses, strabismus, inflammation,
diplopia.


2. Present illness


Review of systems
5. Nose epistaxis, nasal obstruction(difficulty in breathing).
6. Ears earaches, ear discharge, defective hearing, tinnitus,
vertigo
7. Mouth and throat mouth breathing, gum bleeding,
toothaches, stomatitis, gingivitis, trismus, difficulty in sucking
and swallowing
8. Neck pain, limitation of movement, stiffness, torticollis
(difficulty in holding head straight), thyroid enlargement,
enlarged nodes or other masses.


2. Present illness

Review of systems
9. Chest and respiratory chest pain, breast enlargement,
discharged, masses, enlarged axillary nodes, cough, wheezing,
shortness of breath at rest or on exertion, difficulty in
breathing, stridor, sputum production, hemoptysis,
hoarseness, history of pneumonia, bronchitis.
10. Cardiovascular cyanosis, fatigue on exertion, rheumatic
fever.
11.Gastrointestinal nausea, vomiting( frequency, amount
relation to feeding or to cough, color, forcefulness), belching,
flatulence, dysphagia, abdominal pain, hematemesis,
hematochezia, melena, stools(constipation, diarrhea, color,
blood, size, consistency).




2. Present illness

Review of systems
12. Genitourinary pain on urination(dysuria), hematuria,
polyuria, enuresis.
13. Gynecologic menarche, vaginal discharge, pruritus
14. Musculoskeletal weakness, muscle pains or cramps,
fracture, deformity
15. Neurologic seizures, tremors, hypotonia, chorea, delirium,
temper tantrum.
16. Endocrine excessive sweating, excessive thirst


3. Past history

The past history contains information relating to all previous
aspects of the childs health status(infectious diseases,
hospitalizations or major illnesses, operations, trauma,
fractures, head injuries, allergies, other).

4. Family history
Familial diseases and congenital anomalies.




5. Birth history

includes all data concerning
the mothers health during pregnancy(maternal illnesses,
bleeding, toxemia, X-rays, drugs during pregnancy, duration of
pregnancy).
the labor and delivery( duration of labor, type of delivery, e.g.
cephalic, breech, forceps, caesarian, anesthetic, where born).
the infants condition immediately after birth( birth weight,
respiration, resuscitation, cyanosis, jaundice, other problems,
incubator, oxygen, age at discharge from hospital).

6. Immunizations
BCG, Hepatitis B, Diphtheria/pertussis(cellular or acellular)
/tetanus, polio, Measles(give number of administrations of each).





7. Growth and development

The most important previous growth patterns to record are:
approximate weight at 6 months, 1 year, 2 years and 5 years of
age,
approximate length at ages 1 and 4 years, and dentition, including
age of onset, number of teeth, and symptoms during teething.

Developmental milestones include:
age of holding up head steadily
age of sitting alone without support,
age of walking without assistance,
age of saying first words with meaning
school performance
interaction with other children, peers, and adults.



8. Feeding

breast, how long?
bottle
type of milk, composition of formula.
feeding schedule
total amount of milk per day
age at starting cereals, vegetables, fruits, meat, eggs
how often taken, especially sources of iron, ( e.g., red meat,
fortified infant cereals)
vitamin- preparation dose, how long given.
feeding problems