Mother
What are her worries? |
What does she think? |
Quote her verbatim |
Understand her idiom |
Ask her to define her terms |
Start with "tell me about your baby" |
Features of a history
Identifying data |
Chief complaint |
Birth History & Pre natal history |
Sleeping patterns and positions |
Feeding and elimination history |
Innoculations |
Health history and family health |
Older sibling/family problems |
Qs to ask
When does it occur? |
How long has he had it? |
Can you describe it? |
What bring it on? |
Does anything relieve it? |
What makes it worse? |
Pattern and periodicity? |
Associated symptoms? |
What does he do when he has it? |
What have you done about it? |
Clue words:
"doesn't like bread/biscuits" = gluten intolerance
"He loves salt" - losing salt?
"He's hungry after being sick." = mechanical vomiting - pyloric stenosis, GORD
Mother's health
Conception |
Natural/assisted? |
Illness: |
Infections, diabetes, vomiting, bleeding, eclampsia, pre-eclampsia, toxaemia, anaemia, excess weight gain, back pain |
Injuries |
Accidental/On purpose? |
Smoking? |
Birth details
Place of birth |
Interventions |
Type of delivery |
Analgesia |
38-42 weeks is normal |
Birth weight |
Birth height |
Head circumference |
Additional questions
How long was the first/second stage? |
Home birth, hospital birth, midwife? |
Vaginal, planned c-section, emergency? |
Delivery? Position? |
Childhood illnesses:
Coughs + colds, oral thrush, skin rashes, sticky eyes, ear problems, breathing difficulties, bronchiolitis, asthma, constipation, diarrhoea, chickenpox
Nutritional health
Introduced solids? |
If regurgitation = how frequent? What colour? |
Health
Less than 6 wet nappies per day |
Immunisations: |
8 weeks, pneumococcal, rotavirus, MenB |
12Weeks, 6 in 1 - rotavirus |
16weeks, 6 in 1: pneumococcal, MenB |
1 year: MMR, Hib/MenC, pneumococcal, MenB |
Development
6 weeks |
Smilling |
3 months |
Head Steady |
7 months |
Sits unaided |
9 months |
Standing unsupported |
11 months |
Crawling |
12 months |
2 or 3 recognisable words |
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