Paediatric History

Patient demographics:

Name:
Age:
Gender:
Informant:
Address:

Presenting Complaint:

So tell me what brought your child in today? (Patient’s own words)

P/C (symptoms in chronological order):
Onset:
Duration:

History of Presenting Complaint:

Pre-morbid history (When last was your child feeling well?):
a) Time (onset, duration, frequency – episodic or continuous, course)
If episodic, duration and frequency
If continuous, any changes in severity
b) Place (site):
c) Quality (eg. Character of pain, composition of vomitus):
d) Quantity (eg. Severity, amount of vomitus)
e) Alleviating Factors
f) Aggravating Factors
g) Associated symptoms (eg. Fever, diaphoresis, V+D, cough, sputum, etc)
h) Treatment (if any)

Review of Systems:

- General: weight loss, loss of appetite, fever, pain

- CVS: Chest pain, SOB (exertion), SOB (with sweating on feeding), cyanotic spells, palpitations,
fainting/syncope, squatting
- Resp: Cough, wheeze, sore throat, ear ache, hemoptysis, frequent chest infections, history of aspiraton
- GIT: Abdominal pain, vomiting, jaundice, diarrhea, constipation, blood/mucus in stools)
- CNS: seizures, syncope/dizziness, numbness/unpleasant sensations, headaches, visual problems,
weakness/falls, incontinence
- GUS: dysuria, nocturia/enuresis, hematuria, incontinence, stream
- Rheum: joint swelling, limpness, skin rash, hair loss, dry mouth/ulcers, dry/sore eyes, cold extremities
Past Medical & Surgical History:
 General health: how active/ lively, any illnesses
 Chronic illness screen: asthma, sickle cell, epilepsy, thalassaemia, congenital heart disease, diabetes
 Get details in any +ves:
When & how diagnosed, by whom;
Current treatment, changes over time & compliance; #/frequency of attacks, # of hospitalizations (emergency vs
admissions), who is managing it (clinic/private dr & copies of investigations), regularity of clinic visits, complications

Previous hospitalizations and Admissions:

o When (child’s age), hospital & ward, why (P/C &final diagnosis), duration, treatment, complications, follow-up
o Dates, nature of & complications from any operations

Drug History:

 Drug name
 Why prescribed
 Who prescribed & When
 Dosage form
 Dose
 Frequency, duration
  Side effects
 Last taken
 Compliance/adherence

Allergies: drugs, eggs, peanuts, other foods, insect bites, contact

Birth History:
Maternal Antenatal: Intrapartum: Postpartum:

o Planned/Unplanned/Welcomed o Gestational age/due date o Birth weight

pregnancy?
o No. of pregnancies & which baby is
this
o Booking bloods & results (ABO,
Rhesus, HIV, VDRL, SCD, CBC)
o USS: how many, when done
o Supplements (Fe, folic acid) & what
stage of pregnancy she began
taking
o TORCH & other infections
[Toxoplasmosis, Other (syphilis,
VZV, parvovirus B19), Rubella,
Cytomegalovirus, chlamydia,
gonorrhea, HIV, hepatitis, herpes,
Group B Strep, UTIs]
o Maternal illness & complications
prior/ during pregnancy &
hospitalizations; gestational DM,
HTN, pre-eclampsia, epilepsy & if
illness prevented working
o Alcohol, smoking, licit & illicit drugs
during pregnancy?
o Details of labour & delivery
o Which hospital
o C-section (foetal/maternal
indication,
elective/emergency)
o Vaginal
(spontaneous/induced)
o How long after water burst
did she give birth/prolonged
labour, prolonged rupture of
membranes
o Position (breech/normal,
cord around neck,
meconium)
o Assisted delivery
(forceps/vacuum)
o APGAR score (condition &
vigour of infant at birth: pink,
breathing/crying, limp/active)
o Skin-to-skin initiated for ≥ 1 hr
immediately afterbirth
o When was breastfeeding
initiated?
o Was the baby taken away?
/NICU admissions, reasons&
duration
o Jaundice/put under light or
transfused
o Infections & treatment
o Mom & baby discharged
together?
o Congenital abnormalities

Growth/Developmental History:

Current weight and height

Achievement age of developmental milestones (smiling, ability to hold neck, sit, crawl, stand, walk, talk, control of
bladder and bowel)

DENVER (fine & gross motor, language& social/behavioural) must be covered in all points

- For a child >4-5 years:

A global statement such as “the developmental history is normal” is acceptable
- Also include: vision& hearing; bladder& bowel control; school progress-had to repeat& why, grades, rank in
class, absence from school, friends in school known to parents, teacher concerns, school performance
compared to other siblings; temperament, behaviour, sleeping
Immunization:

Ask to see card, where vaccines received (LHC or private); last and next appointments. This may be summarized as:
“immunisations are up-to-date”

NOTE: for sickle cell <3yrs ask about pneumococcal

Nutritional History:

 Breast/bottle-fed
Breast - how often, how long, 1/both sides; when and why stopped
Bottle-type of formula, how much, how often, how is it mixed/quantities
 Tolerance for feeds
 Weaning age
 Addition of solids-
 Food groups, typical meals
 24-hr recall (breakfast + lunch + dinner + 2 snacks between) if over/under-feeding suspected
 Child’s attitude toward eating; vitamin supplements
 Ask teen girls about attitude towards their body and eating!

Family History:

 Age, state of health of each parent & sibling; parents’ jobs + highest level of education attained
 If siblings have same father/mother
 Any h/o sickle cell disease, CF, miscarriages, birth defects, childhood malignancies, asthma, chronic illness
screen
 Any family members with similar problems

List the mother’s pregnancies in chronological order, giving details& outcomesof each. If siblings have died, note the
nature of the condition leading to the death& the results of postmortem or other examinations.

Chronic illnesses among members of the family need to be noted.

If the PC& HPC suggest the possibility of a heritable condition, explore the family for the pattern of similar conditions
within the immediate family& forbears.

Check for parental consanguinity. Mention only if clearly relevant to the current admitting problem.
Social History:

 Explore living conditions for exposure to specific infections, poisons & toxic substance, psychological &
emotional factors which might be involved in the present illness
 Where does the family live & amenities?
 Type & size, owned/ rented; stairs, toilets, cooking facilities, running water vs tank (how often cleaned) or
buckets (covered); electricity; garbage collection, refrigeration, poisons/toxins, guns, neighbors
 # in household; who lives in the household(smokers)
 Where child sleeps
 Pets
 Parent occupation/unemployment, use of alcohol/drugs, parental psychiatric disorders, partnerships, get an
idea of family income
 For asthma: carpets, drapes, pet dander, stuffed animals, smokers in household

Always ask adolescents about EtOH/tobacco/illicit or IV drug use& if they’re sexually active, use of barrier protection;
school: What level are they in? Grades? Behavioral problems? Teachers’ concerns?

Psychosocial History:

 Is the child happy at home/school; child’s preferred leisure/play activities

 How illness/admission affects the family; how patient/siblings/ parents cope with illness
 Extra support from extended family, financial aid, NGOs

SUMMARY

Positives & important negatives that impact on differential; approx. 5 lines with pertinent information that
summarizes the important parts of the history.

Include identifying info, PC, a very brief description of the HPC plus essential details from the ROS, PMSHx, and FSH