This document provides guidance on conducting a pediatric history and physical examination. It outlines the key components to cover in the patient's history, including their chief complaint, past medical history, allergies, social history, neonatal history, vaccinations, family history, current illness, medications, and development. It also describes how to conduct the physical examination and interview the family and child in a professional yet sensitive manner using open-ended questions, empathy, and clarification. The goal is to obtain the essential medical information needed for diagnosis and treatment.

1. Pediatric History and Physical Examination Dr Abdullah Aburiziza Allergy/Immunology Consultant Assistant Professor, Pediatric Department, Um Al-Qura University

2. HISTORY ID Past Medical History Allergy History Social History Chief Complain Neonatal History Vaccination History Family History History of present illness Drugs History Developmental History

3. Interview Techniques Family &Child Professional, yet sensitive and nonjudgmental Manner Open-ended questions Acknowledge parents concerns Closed ended questions Empathize Repetition of important phrases Guide the interview and summarize Clarification Medical terms Confidentiality

4. ID

5. Chief Complain 1,2 or max 3 Chief Complains Duration of Chief Complains

7. Duration

8. Progression

9. Site

10. Size

11. Severity

12. Aggravating factors

13. Reliving factors

14. Associated Symptoms1,2 or max 3 Chief Complains Diagnosis & Differential

15. Past Medical History PMH: Similar illness PMH: Chronic diseases, diagnosis, progression PMH: Admission, numbers of admission PMH: Related diseases Past surgical History

16. Neonatal History Prenatal History Antenatal History Postnatal History

17. Drugs History Duration of usage Method of usage Availability and cost Dosages Recent changes in dosage Complications and side effects Help from the family Compliance

18. Allergy History Drug Allergy Food Allergy Inhalant Allergy

19. Vaccination History Developmental History

20. Social History Travel Hx Family Structure Home environment Family income Hx Smoking Cope with the disease Education Hx School

21. Family History Family History of Similar disease Medications used in family Family History of related disease (Disease specific ) Family History of infant death or miscarriages

22. HISTORY ID Past Medical History Allergy History Social History Summery Chief Complain Neonatal History Vaccination History Family History History of present illness Drugs History Developmental History

23. Physical Examination Initial: Hand Washing, Introduction, Privacy, Permission, Vitals and anthropometrics measurements, plotted on the chart Specific: